AUTHORIZATION TO EXCHANGE CONFIDENTIAL INFORMATION

I, 

hereby authorize Melissa Paramo/Paramo Therapy Group to exchange confidential information regarding my treatment with 

This Authorization permits the exchange of the following informaton:

Check all that apply

• Any and All Information Necessary
• Diagnosis
• Progress to Date
• Patient Records
• Treatment Plan
• Clinical Test Results
• Summary of Treatment
• Prognosis
• Dates of Treatment
• Other (please specify)

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I understand that I have a right to receive a copy of this authorization.  I also understand that any cancellation or modification of this authorization must be in writing.

To accept this contract, type your name below

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Copyright California Association of marriage and Family Therapists. Rev 02/04

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Warmly,

The Paramo Therapy Group

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