AUTHORIZATION TO EXCHANGE CONFIDENTIAL INFORMATION-(revised 2024)

Mitchell Rosen, LMFT

43537 Ridge Park Drive

Temecula, CA 92590

(951) 541-3158

Authorization to Exchange Confidential Information

I [Name of Patient and date of birth]

hereby authorize Mitchen Rosen, LMFT to exchange confidential information regarding my treatment with:

[name and function of the person(s) or entities to which information is to be exchanged]

This Authorization permits the exchange of the following information

If other, please explain:

I authorize the exchange of the information described above for the following purpose(s):

The recipient may use the information described above solely for the following purpose(s):

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.

By:

First NameLast Name

Date- this authorization shall remain valid for at least one year from date submitted or until family law case is completed.

*If signed by other than Patient, please indicate the relationship between Patient and his/her Representative:

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