HIPAA & Privacy Practice Notice & Consent

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Disclosures

Email *

Today's Date *

YYYY

I understand that I am about to acknowledge my patient rights were read fully and understood.

Yes

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FULL LEGAL NAME *

MAILING ADDRESS *

PHONE NUMBER *

EMAIL ADDRESS *

REASON FOR REQUESTING SERVICES *

I WAS REFERRED BY *

I am giving permission for my information to be released to the following individuals, and I understand I can take permission away at anytime for any reason by contacting the agency. (You must include NAME, EMAIL, PHONE, ADDRESS, AND RELATIONSHIP TO YOU.) *

What can be released from your official records? *

Assessments/Diagnoses/Reason for Treatment

Progress Notes/Progress Reports

Discharge Information

I don't want to release my records (if DCS is paying for services you will be required to pay for your services.)

Other:

Required

I UNDERSTAND I AM ABOUT TO CONSENT FOR SERVICES TO BE SET UP ONLINE OR BY PHONE. *

YES

Required

SIGNATURE (TYPE NAME HERE) *

On this day, *

YYYY

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