Midwest Wellness

RELEASE OF INFO

Authorization Form

  • Please enter the name of the person, persons, doctor, group, etc... who will receive your information. This is the "Recipient."
  • Please enter your name or the client's name and date of birth.
  • Please enter the name of your therapist at Midwest Wellness.
  • Authorization Expiration Date (If no authorization expiration date is entered then this agreement will continue indefinitely).
  • Date Format: MM slash DD slash YYYY