• I,

  • do hereby authorize New Vision Counseling Center to


  • I understand that unless otherwise limited by state or federal regulations, and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time by giving written notice to New Vision Counseling Center, LLC. If no prior notice of revocation is received, this consent will expire automatically two (2) years after the date indicated thereon. I further understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA Privacy rule.
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