Authorization for Use or Disclosure of Protected Health Information Form

Authorization for Use or Disclosure of Protected Health Information Form

Redefining You Therapy, Inc respects your right to privacy. This "Authorization for Use or Disclosure of Protected Health Information Form" provided by Redefining You Therapy Incorporated follows HIPPA guidelines.
Click HERE to return to RedefiningYouTherapy.com
I, the undersigned, hereby authorize Redefining You Therapy to disclose the specified individually identifiable health information to and/or obtain information from the person/organization listed below.This authorization includes release of information concerning treatment and/or psychiatric/psychological conditions. The following may be released.

AssessmentsDiagnosisRecommendationTreatmentReview of RecordsOther, specify below
Full Name*

First NameMiddle NameLast NameSuffix
Agency*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Client Name*

First NameLast Name
Client/Guardian E-Signature*

First NameLast Name
A therapist from Redefining You Therapy has witnessed this document.
Today's Date*
Should be Empty: