Home
About
Services
Getting Started
Resources
Contact
Blog

805-234-2573 | amigracelcsw@gmail.com

Authorization for Release of Information copy

September 1, 2016 by Ami Leave a Comment

Authorization for Release of Information copy

181 Tank Farm Road, Suite 120
San Luis Obispo, CA 93401

805-234-2573
amigracelcsw@gmail.com

Send a Message

Name *

E-mail *

Phone

Comment or Message

Terms of Use *

Yes, I want to submit this form

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Message

A Bright Site by Brighter Vision

Copyright © 2023 · Bubbles on Genesis Framework · WordPress · Log in