PHI Release Form

Please complete the following form prior to your first appointment with us. If you have any questions, please call us at 859.554.0740.

Client Information

Adult Client / Parent / Guardian Name Completing Form(Required)
Client's Name(Required)
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Release Information

I hereby authorize Willow Creek Counseling Center to release the following protected health information:(Required)
check all that apply.
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I understand there are statutes and regulations protecting the confidentiality of information in medical records and that the above information is only released with my understanding and permission. I understand that I can revoke this authorization at any time by sending a written request. I also understand I have the right to inspect and have a copy of the health information described in this authorization. I understand that the person or organization to whom I am releasing this information may not be covered by federal privacy regulations, so the information might not be protected by the entity I have authorized to receive it. I have had the opportunity to have my questions answered about this authorization. I understand my refusal to sign will not affect my abilities to obtain treatment here. I hereby acknowledge this consent is truly voluntary.
Copy of Form(Required)
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