COUNSELING OFFICE OF HEIDI WEIPERT
218 S. Warren Ave.; Big Rapids MI. 49307; 231-683-2101
Release of Information Form
Client's Name:
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First Name
Last Name
Client's Birthdate:
*
-
Month
-
Day
Year
Date
In the box below, I am naming the person and/or place of business that Ms. Weipert may exchange information:
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Email address of the person/place of business to exchange information:
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example@example.com
Phone Number of the person/place of business to exchange information:
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Please enter a valid phone number.
Address of the person/place of business to exchange information:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Information to be exchanged:
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Any clinical information
Billing information only
Scheduling information only
ONLY attendance and verification of compliance in treatment
The purpose of the disclosure is to
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Coordinate care with a medical professional
Coordinate care with a teaching professional
Share information with a legal professional
Include a family member in treatment
Include someone in billing matters
Include someone in transportation matters
This authorization shall remain in effect until:
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One year from the date of this signed document
Other
I understand that this information may contain references to mental health, substance abuse, and/or HIV. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken to comply with it. I understand that per applicable state and federal law, the information disclosed under this authorization may be subject to further disclosure and may no longer be protected by federal regulations. I further acknowledge that the information being released was fully explained to me and my consent is given on my own free will.
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Typed Name
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