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AUTHORIZATION AND RELEASE OF MEDICAL
The following document contains important information about how we treat your medical and healthcare information and your rights as a client or patient.
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AUTHORIZATION TO DISCLOSE PROTECTED HEALTH
As indicated on the form, specific authorization is required for the release of information about certain sensitive conditions, including: Mental health
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Hipaa 2-17-04.rtf
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:.
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