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214.396.5200 | 11955 DALLAS PKWY, FRISCO | 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
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Iowa
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Louisiana
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Ohio
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
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Tennessee
Texas
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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
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Last
Relationship to Patient
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Mother
Father
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