Consent for Release or Exchange of Confidential Information

Patient Name

I hereby grant permission to the following practitioners, individuals or institutions to give any needed information, including copies of my medical and psychiatric records, regarding my care. In addition, I grant consent to Dr. Kenneth Cohen to discuss clinical aspects of my care with same. This consent extends from today and expires five years after the date of signing.

Name

Name

Name

Name

Name

I understand that I may revoke this consent at any time by informing all of the above parties in writing. The parties named above are hereby released from all legal liability that may arise from this exchange or release of information.