.

Center for Professional Health

Authorization Letter

 
 
  
I____________________________________________, hereby give permission to William H. Swiggart, MS, LPC/MHSP to send a letter documenting my completion of the CME Course, (Name of the Course)_______________________________________, held on ­­­­­­­­­­­­­­­­­__________________at the Center for Professional Health to the following:
 
 
List Name(s) of person or agency and address: (PLEASE PRINT)
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
 
Purpose: Documentation of completion of CMECourse:
 
No other information regarding my attendance will be released or letters sent without my written consent. I understand that the letter may be subject to re-disclosure by the some recipients and may no longer be protected by federal and state privacy rules.
 
Time Limit: I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: _______________________________________
 
 
Participant: ______________________________________
 
Date: ___________________________________________
                                               
Signature________________________________________

 

FAX  completed authorization letter to (615)936 0676. Thank you.

 

 

 

This page was last updated January 4, 2010 and is maintained by