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FORM – Release of Information
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FORM – Release of Information
FORM – Release of Information
2020-04-20T14:02:21-04:00
I hereby authorize Refreshing Waters Counseling to release my information to:
Released to name
Purpose
Field Group Open
Name
*
Email
*
Phone
*
Relationship
*
Field Group Close
Patient's First Name
*
Patient's Last Name
*
Patient Address
Patient City
Patient Zip
Patient State
Alabama
Alaska
Arizona
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Connecticut
Delaware
District of Columbia
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New Hampshire
New Jersey
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North Carolina
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Ohio
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
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Vermont
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Washington
West Virginia
Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Patient Phone
*
Date of Birth
*
MM
DD
YYYY
Field Group Open
I authorize the following information to be released from my records
*
All dates of service
Single date of service
A range of dates of service
All Dates
Through
Date of service
Date Format: MM slash DD slash YYYY
Date of service start
Date Format: MM slash DD slash YYYY
Date of service end
Date Format: MM slash DD slash YYYY
Field Group Close
Please select the appropriate item(s)
*
Initial Assessment
Session Notes
Treatment Plan
Emergency Contact Only