Patient Consent or Authorization

PATIENT CONSENT OR AUTHORIZATION
FOR RELEASE OF CONFIDENTIAL INFORMATION TO OTHER MEDICAL SPECIALISTS

Enter name of client, or parent/guardian

I hereby authorize: WELLNESS 4 LIFE, INC. to release confidential information consisting of any
medical, psychiatric/psychosocial information, alcohol/drug abuse, sexually transmitted disease, HIV,
AIDS, adult or child abuse, or case management information, including any information received from
other health care providers concerning diagnosis and treatment for its use in determining a claim for
such diagnosis or treatment, etc. regarding

Layout

Patient

D.O.B.

to WELLNESS 4 LIFE INC. consultant Dietitian for the purpose of assisting with diagnosis, treatment, delivery of care and other services.

Florida law requires that information contained in medical records be held in strict confidence
and not be released without your written authorization. The authorization you sign on this page
will remain in effect until you request in writing that your authorization be withdrawn,
which you may do at any time. You have a right to receive a copy of all parts of this authorization.

Layout

Signature of Client or Parent/Guardian

Date

Layout

Signature of Witness

Enter Name

Date