859.554.0740    Client Portal

859.554.0740
Client Portal

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.
MM slash DD slash YYYY

Acknowledgement

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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