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Release of Information Form

Please fill out the form below to submit a Release of Information request. You may also download the PDF copy of this form, complete and submit in-person or send to

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Requested Information

Release of Information Terms

The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services.

Unless sooner revoked, this authorization expires on the 60 days after my last appointment.

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to the therapist I am working with at Sage Recovery & Wellness Center. I understand that I may revoke this authorization, by requesting in writing, a discontinuation of this document to 7004 Bee Caves Rd, 2-200, Austin, Texas 78746. I also understand that the written revocation must be signed and dated with a date that is later than the date of this authorization. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.

I consent to the release of privileged information and waive the privilege of confidentiality afforded for medical and mental health care, alcohol and drug rehabilitation, and authorize Sage Recovery & Wellness Center’s staff to communicate with the individuals listed below to exchange any information for the purpose of clarifying and enhancing my care and treatment.