Authorization for Release of Information

Today's Date

MM

DD

YYYY

Client's Name

First Name

Last Name

This exchange of information is for BILLING purposes ONLY. I, the client, authorize Jeremiah Dieujuste to exchange information with the following individual:

Release Information To

First Name

Last Name

Expiration Date

I understand that this authorization expires one year from the date it was signed unless revoked in writing prior to its expiration date.

Client's Signature

First Name

Last Name