David W. Sprague, Ph.D.
NYS Licensed Psychologist
113 Main Street
Batavia, New York 14020
585-344-4573; Fax. (585) 344-1495

AUTHORIZATION FOR RELEASE OF INFORMATION

I,
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(Print Patient Name)

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(Birthdate and Social Security Number)

give permission to:

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(Name of agency, therapist, doctor, school, etc.)

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(Complete Address)

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(Phone & Fax Number)

to
____ DISCLOSE information to      And/or           ____ OBTAIN information from Dr. David W. Sprague, Ph.D.

INFORMATION TO BE DISCLOSED/OBTAINED

___ Psychiatric Information
___ Social Welfare Data
___ Psychological Testing
___ Rehabilitation Records
___ Education Records
___ Legal Information
___ Medical Information
___ Other___________________________________

Limits:_______________________________________________________________________________

I may revoke this consent at any time. If I do not revoke it, this consent will expire one year after I have terminated treatment with Dr. Sprague.

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(Signature of Patient , Parent or Guardian) (Date)

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(Signature of Witness) (Date)