Release Of Info

Release of Information

Throughout this program, there are options for several different providers to assist you on your health and wellness journey. Should you choose to work with any of these providers, it is important that lines of communication stay open between them in order to assist you most effectively and efficiently on your path. Thus, the occasional sharing of relevant information will allow the team to serve you best. Your authorization is needed for this release of information to take place

I, (client name), hereby authorize me360 to release and exchange information pertaining to my coaching with me360.

I understand that this authorization shall remain valid from the date of my signature below and for 12 months thereafter. I have been informed that I may revoke this authorization by written or email communication to me360.

I certify that this form has been fully explained to me and that I understand the content.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

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Signed by Michael Leonardi
Signed On: April 14, 2021

Timestamp

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March 8, 2021 1:10 pm EDT

Release Of Info Uploaded by Michael Leonardi - mleonardi@me360health.com IP 99.24.222.23

April 14, 2021 4:24 pm EDT

Document owner ellie@rawfitnesspersonaltraining.com has handed over this document to mleonardi@me360health.com 2021-04-14 16:24:20 - 99.24.222.23