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Get Mind Therapy Clinic Release Of Information Consent

Ive my records To From Name: Entity: Phone: Fax: Address: If releasing my records to Mind Therapy Clinic, please send to 240 Tamal Vista Blvd., Suite 160, Corte Madera, CA 94925. INFORMATION TO BE RELEASED* Evaluation Testing Results Lab Results Diagnosis Progress Reports Medication Info Summary Reports Entire Record Updating Files The above information will be used for the following purposes only:.

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