CONSENT FORM FOR RELEASE OF MEDICAL RECORDS

CONSENT FOR RELEASE OF MEDICAL RECORDS - Aimee E. Short, LPC

9855 E Larkspur Dr., Scottsdale, Arizona 85260, Email: aimee@iamdrshort.com, Phone: (480) 329-5636
Patient's Full Name
As listed on the record
I hereby authorize the release of my medical records, created by Aimee E.

Short, LPC, to the individuals listed below for the purpose of:
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I acknowledge that this consent form allows Aimee E. Short, LPC, to access, review, and disclose my medical records as required for the stated purpose.

I am aware that this release will remain valid and in effect until I formally revoke this permission in writing.

I understand that the information disclosed may include, but is not limited to, medical and psychological evaluations, treatment plans, progress notes, test results, and any other relevant medical or mental health

I acknowledge that my privacy rights will be respected and that the disclosed information will be handled in accordance with applicable laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA) and other relevant state and federal laws.

I hereby release Aimee E. Short, LPC, and any individuals or entities involved in the release, transfer, or disclosure of my medical records from any liability that may arise from the release of said records for the specified purpose.

I understand that I have the right to request a copy of this signed consent form for my records.
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CONSENT FOR RELEASE OF MEDICAL RECORDS - Aimee E. Short, LPC