Release of Information Authorization

Phone

This field is for validation purposes and should be left unchanged.

Sinnergy Wellness Group

R · E · S · T · O · R · E M N T

Authorization Form — Release of Information

Authorize your care team to communicate with Kristine — complete anytime, as often as needed.

Tues · Thurs · Sat | info@sinnergywellness.com | (480) 382-6109 | Fax (855) 789-1895

📋 Add a provider anytime. Use this form whenever you want Kristine to coordinate with someone new — your PCP, therapist, psychiatrist, specialist, or anyone else on your team. You can authorize multiple providers in one submission. This form can be completed as many times as you need — there's no limit.

1 · About You

1Client Information

First name(Required)

Last name(Required)

Date of birth(Required)

Provider at Sinnergy Wellness Group

Topics you do NOT want discussed (leave blank if none)

2 · Scope

2I authorize my provider to

Check all that apply.

Scope of Authorization

Discuss treatment progress, session themes, and clinical recommendations

Obtain medical records, lab results, or clinical notes

Release nutrition assessment, session notes, or treatment plan

Financial documents only (invoices / superbills)

This authorization expires one year from the signature date. You may revoke it at any time in writing. Revocation does not affect actions already taken in reliance on this authorization.

3 · Authorized Individuals

3Provider(s) to communicate with

Providers(Required)

Provider Name

Role / Specialty

Practice / Organization

Phone

Fax

Add one provider at a time. Use the “Add” button to add more — there's no limit.

4 · Authorization

4Signature

By signing below, I authorize the disclosures described above. I understand this is voluntary and does not affect my ability to receive services.

Client or legal guardian signature — type your full legal name(Required)

Date(Required)

Parent / guardian printed name (if minor)

R.E.S.T.O.R.E. MNT · Sinnergy Wellness Group

Kristine Sinner, MS, RDN, LDN, CEDS-C · NPI 1073918116
8700 E. Vista Bonita Suite 236 · Scottsdale, AZ 85255
(480) 382-6109 · Fax (855) 789-1895 · info@sinnergywellness.com
All clinical content and forms are the exclusive intellectual property of Kristine Sinner and Sinnergy Wellness Group. © 2026 Kristine Sinner. All rights reserved.