Consent for release of Information Registro de Información
I hereby authorize:
Yahara Counseling Center, LLC
Monona Drive, Suite 201, Monona, WI 53716
(Check one or both. By checking both you are authorizing an exchange of information between the agencies/individuals listed) Cliente seguimiento
I understand that:
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My records are protected under State and Federal regulations governing confidentiality
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I will receive a copy of this form and have the right to inspect/receive a copy of the materials to be disclosed
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Federal privacy law requires notification that my health information, once disclosed to individuals or organizations not subject to HIPAA, may no longer be protected by HIPAA.
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I may revoke this consent at any time by giving written notice to YCC service provider(s), except to the extent that information has already been disclosed based on this release.
Type your full name and date into the fields below so that they match the information below the field to sign this document Escriba su nombre completo y fecha en los campos a continuación para que coincidan con la información debajo del campo para firmar este documento
Your Information Release has been Sent!
Thank you for taking the time to complete this form. Your therapist will be following with any questions via email.
