Hippa Release Agreement - Breathe Easy Therapy

Full Name(Required)

Date of Birth(Required)

Person Name (If Applicable)

Title (If Applicable)

Practice (If Applicable)

Address (If Applicable)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (If Applicable)

Email (If Applicable)

Fax (If Applicable)

Full Name of Client(Required)

Client Signature(Required)

Full Name of Minor (If Applicable)

If there are multiple parties requesting release of information please complete this form for each person.