Authorization Release

Whiting & Associates LLC


Individual, Child, Adolescent & Adult Treatment

632 SE 4th Street      (816)554-7750
Lee's Summit, MO 64063


Authorization for Release of Information

Please fill in your name.

to release to and/or furnish the following information from my records to the above named person, firm, clinic, school, hospital or social agency:

I hereby release the above named party from any liability for information furnished pursuant to this authorization.  This release remains valid for the duration of treatment period, if not specifically invalidated earlier, of the above named patient and photo static copies of this authorization will be considered original.

We've added this question for your security and safety. Thank you for your patience.
Enter the characters shown in the image.