Evoice release consent form

Authorization to Send Invoices by Email I, ____________________________, hereby authorize Anne Westcott, L.I.C.S.W. to send invoices for psychotherapy services via email. I further authorize use of my email for administrative transmissions. I would like to receive invoices at the following email address: _____________________________________ email address I may revoke this consent in writing at any time. ________________________________ ______________________________ Signature Printed Name ______________________________ Date

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