Authorization for Release of Information

Authorization for Release of Information : I authorize Dr Saurabh Gupta MD to provide patient information or to obtain patient information .

TYPE OF RECORDS AUTHORIZED: Psychiatric/Psychological Evaluation and/orTreatment Drug/Alcohol Evaluation and/orTreatment

SPECIFIC INFORMATION AUTHORIZED: Assessments Progress Notes Laboratory Test Results Diagnostic Impression Discharge Summary Treatment Plans Treatment Summary.

Dr Saurabh Gupta MD 410 Foulk Road, Suite 106, Wilmington, DE 19803.

Valid for six months from date signed