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11955 DALLAS PKWY, FRISCO | M-F 8-6 SAT 9-12 SUN 3-5
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11955 Dallas Parkway, Frisco
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M-F 8-6 | Sat 9-12 | Sun 3-5
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CONSENT TO RELEASE INFORMATION
Admin: Consent Release of Information
Michael
2021-02-25T08:30:41-06:00
Patient Name
*
First
Last
Patient Date of Birth
*
MM slash DD slash YYYY
I authorize:
Joanie Leach, LPC
Pediatric People PLLC
11955 Dallas Parkway, Suite 400
Frisco, TX 75033
To disclose and/or obtain treatment information from the following:
Name
*
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
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Montana
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New Hampshire
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New York
North Carolina
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Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Email
Authorization to Release Information
*
I acknowledge that information about me may be released, discussed, or disclosed. I understand that my records are protected under Federal Regulations governing Confidentiality of Protected Health Information (PHI) under HIPAA and Confidentiality of alcohol and drug abuse patient records, 42 CFR Part 2 and cannot be disclosed without my consent unless otherwise provided for the regulations. I also understand that I may revoke this authorization at any time and must do so in writing and present this written revocation to my therapist. I understand that once information is disclosed as per my authorization, the recipient, in accordance with eh applicable laws and regulations, may re-disclose the information and it might not be protected by federal or state privacy regulations.
Parent or Legal Guardian
*
First
Last
Relationship to Patient
*
Mother
Father
Legal Guardian
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Date of Signature
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MM slash DD slash YYYY
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