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.