Authorization for Release of Information Please enable JavaScript in your browser to complete this form.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. Authorisation *to releaseto obtainThird ChoiceName of patient *date *name of guardian if patient minor *Valid for Six months from date signed *Submit