• Consent to Release Private Health Information

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  • I consent for Kentucky Counseling Center, LLC DBA Counseling Now and those representing this group to share my private health information with the following individuals and/or entities. The company is permitted to send and receive information to and from those named below:


  • I understand that I have the right to revoke this authorization, in writing, at any time by sending a notice to Kentucky Counseling Center, LLC DBA Counseling Now. I understand that a revocation is not valid to the extent that Kentucky Counseling Center, LLC DBA Counseling Now has acted in reliance on such authorization. A copy of this release shall have the same force and effect as the original.

    NOTICE TO RECEIVING PARTY: You may not re-disclose any of this information unless the person who consented to this disclosure specifically consents to such re-disclosure. 

    I understand that there is a potential for disclosure of this information by the recipient, and if that occurs, federal law may not protect the information.

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