Authorization to Use or Disclose Protected Health Information


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I understand that my health information may contain the following types of sensitive information and I expressly and voluntarily give permission to release the following: 

I understand that I may revoke this authorization at any time by requesting such of the above referenced company in writing, unless action has already been taken in reliance upon it.

 

 

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InMindOut Emotional Wellness Center https://inmindout.com
Signature Certificate
Document name: Authorization to Use or Disclose Protected Health Information
Unique Document ID: ad15f9d685a590bf3c0ea0251024a04471a93232
Timestamp Audit
October 17, 2017 12:03 pm CDTAuthorization to Use or Disclose Protected Health Information Uploaded by Amanda Bergeron Bergeron - amanda.bergeron@inmindout.com IP 23.122.45.227
January 15, 2018 11:38 am CDT Document owner amanda.bergeron@inmindout.com has handed over this document to imo@inmindout.com 2018-01-15 11:38:10 - 23.122.45.227