I, the undersigned patient or legal representative, hereby authorize Nathaniel Witherell to disclose or obtain health information, including if applicable, information relating to the diagnosis or treatment of mental illness, drug and/or alcohol abuse and confidential HIV related information regarding:
The Friends of Nathaniel Witherell is a 501(c)(3) non-profit organization committed to raising funds and otherwise enhancing the quality of life for Nathaniel Witherell’s residents. Charitable contributions to The Friends of Nathaniel Witherell are fully deductible as allowed by law.