Authorization form

Please enter the name of the person, persons, doctor, group, etc... who will receive your information. This is the "Recipient."

Please enter your name or the client's name and date of birth.

Please enter the name of your therapist at Midwest Recovery and Wellness.

Authorization Expiration Date (If no authorization expiration date is entered then this agreement will continue indefinitely).

Filled out by (Client or Client's Representative):