Professional Release Form

DOWNLOAD FORM

Please fill out the form below or download the professional release form with the button above and fill it out at your convenience. Please email us if you have any questions. You can send completed paper forms to:

403 W. Cool Dr.
STE 107
Tucson, AZ 85704

or fax to:
520.329.8311

AUTHORIZATION TO RELEASE REPORT
Patient Name:*
First Last
Date of Birth:*
Date Format: MM slash DD slash YYYY
Upon completion, the final neuropsychological report will be released to your referring doctor:
Additionally, If you would like your neuropsychological report sent to any other medical provider(s) please list them below. Also, please list the phone and fax number for the medical provider, to ensure we are sending it to the correct office.
Medical Provider's Name
Phone #:
Fax #:
Medical Provider's Name
Phone #:
Fax #:
Signature
Date*
Date Format: MM slash DD slash YYYY

By clicking the submit button, you authorize the transmission of your personal health information to be sent over email. We take every effort to ensure that your information stays safe. All information is double encrypted and password protected.

Professional Release Form

DOWNLOAD FORM

AUTHORIZATION TO RELEASE REPORT