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Authorization to Exchange, Obtain or Release Information Form
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I hereby grant Branched Out Therapy, Inc. permission to communicate with the following person or agency:
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For the Purpose of: (Check All That Apply)
Coordinating Care With Other Professionals
Providing Continuity of Services
Updating Therapeutic Progress
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I grant permission to exchange information via written and mailed report, phone call, meeting, email, or fax.
I understand that unless revoked, this authorization will remain valid until written revocation of this authorization is presented.
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