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CONSENT TO RELEASE INFORMATION TO PRIMARY CARE PHYSICIAN

Communication between your therapist and your primary care physician is important to help ensure that you receive comprehensive and quality health care. This information may include diagnosis, treatment plans, progress, and medication, if needed. You may revoke this consent at any time except to the extent that action has taken place in reliance upon it and that, in any event, this consent shall expire one (1) year from the date of signature, unless another date is specified.

Consent Release/Primary Care Physician
Date of Birth
Month
Day
Year
Consent
Consent
Physician Address
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Date
Month
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Year
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Date
Month
Day
Year
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