Authorization for Release of Information

Michele D. Shieldes, Pllc / Innovative Therapy Group

I authorize Michele D. Shieldes, PLLC / Innovative Therapy Group and its therapists and employees to use and/or disclose the above-named patient’s protected health information as described below.  The use and disclosure of information may include, but is not limited to, verbal, written, electronic, or telephonic communication.

Expiration:

I understand that I may revoke this authorization at any time by providing written notice to Michele D. Shieldes, PLLC / Innovative Therapy Group. Revocation will not apply to information already released in reliance on this authorization. Information disclosed in compliance to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.