Julie Wood, MA, LMHC

Bellefield Office Park
Woodridge Building

1715 114th Avenue SE

Bellevue, WA 98004

Authorization for Release of Information

I, ____________________________, hereby authorize Julie Wood, LMHC to release information, including the following,

_____                Diagnosis

_____                Treatment information

_____                Coordination of treatment

_____                Other

I understand that my express consent is required to release any health care information related to testing, diagnosis and treatment of HIV, sexually transmitted diseases, mental health, and/or drug and alcohol use. If I have been tested , diagnosed, or treated for any of the above, you are specifically authorized to release related health care information.

Information may be released to:

_____________________________________

 

_____________________________________

 

_____________________________________

 

_____________________________________

I authorized Julie Wood, MA, to discuss treatment if appropriate. This release of information may be used solely for treatment, insurance claims, and legal purposes. The authorization expires in 90 days for date signed. It may be revoked by written request,

_____________________________________                      ____________________________

Signature                                                                                               Date

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Name- Printed