Consent Authorization for Release of Information

I hereby authorize:

Building Bridges Through Communication, LLC
4500 Hillcrest Road, Suite #120
Frisco, Texas 75035
Phone: (469) 634-6272
Fax: (214) 975-1012

To release the following information from the health records of:

Patient's Name:

Information to be released:

Information to be released:

Information to be released to:

Name
Address:

This authorization will remain in effect until revoked by me in writing:

Clear Signature