Authorization for the Release of Information

Patient's Name (First, MI, Last)

I hereby authorize and give consent for Dr. Karin Varblow, MD, and the below individual or

practice to exchange the personal health information regarding myself or my child, for the

purposes of evaluation, treatment, and coordination of care.

Provider Name

Provider Email

Phone

This authorization is valid until the

expiration date listed below, or 90 days after the termination of treatment, whichever comes first.

Expiration Date (Optional)

Signature

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Date