AUTHORIZATION TO EXCHANGE HEALTH INFORMATION

Educate. Motivate.

AUTHORIZATION TO EXCHANGE HEALTH INFORMATION

I authorize health information to be exchanged between Tricia H. Rogers, MS-CCC and the parties listed on this form for:

I grant this permission between Tricia H. Rogers, MS-CCC and the parties listed below. Permission is granted for the duration of treatment with Tricia H. Rogers, MS-CCC. I may revoke my permission in writing at any time.

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