RELEASE OF INFORMATION

RELEASE OF INFORMATION
,do hereby authorize any related representative at MindDevelopers Counseling & Supervision to
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do hereby authorize MindDevelopers Counseling & Supervision to*

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Treatment ProgressTreatment PlanningMedical TreatmentReimbursement for TreatmentPsychiatric EvaluationSocial HistoryTreatment SummaryDiagnosisChild Custody/VisitationCompetency to Stand TrialOther
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 MindDevelopers Counseling & Supervision PC. 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.
I have read, or had read to me, the above and understand the contents.*

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I authorize this information to be faxed to the party indicated above and understand the limits of confidentially which doing so creates.I have read and received the ROI; however, at this time I do not have anyone I wish to release information to. I am aware that I can make changes as necessary and at anytime by completing this form.
By signing your name you acknowledgement completion of this form.*

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