Release of Information Form

This release form covers basic information exchange necessary for our work together, and is in accordance with what the insurance company requires. Please refer to the Notice of Privacy Practices for explanation of when/how this information may be released.

Name of client(Required)

First Last

Is the person signing the release the client?(Required)

I am the client

I am NOT the client

Name of person signing release, if not client(Required)

First Last

Relationship to client(Required)

Authorizations

I authorize the release of any medical or other information necessary to process my insurance claim.(Required)

YES

I authorize payment of medical benefits to Glenda Rice, MA, LPC.(Required)

YES

Contacts

In order to confirm/reschedule appointments or for other necessary contact, I request that I be contacted as follows:

Phone

Text

Select only your valid contact options.

Phone number(Required)

Email(Required)

Signature

Client Signature(Required)

By typing your name, you agree that it will serve as your signature for this release form.

Name

This field is for validation purposes and should be left unchanged.

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Start your healing
journey today

Schedule an appointment

Glenda L. Rice, MA, LPC
Psychotherapy and Consultation

5909 West Loop South, Suite 470
Bellaire, TX 77401 ( Map )

713-664-5513 • 866-888-6283 (fax)

Release of Information Form

Authorizations

Contacts

Signature

Start your healing journey today

Start your healing
journey today