Notice of Changes to Client Information

Please use this form to provide updates to your patient information (phone, address, email, insurance, how you wish to receive appointment reminders, consent to receive and release client information).

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I hereby authorize Affiliated Counseling Services to receive and release my information including (but not limited to) progress notes, treatment/discharge summary, psychological/neuropsychological assessment, healthcare records, educational records to the parties named above for continuity of care. I understand that this consent is reversable upon written request, except to the extent that action has been taken (e.g., information has already been released in accordance with this authorization). Please note if no individuals are listed this information will not be released, except in the circumstances listed in the privacy policy or as required by law.
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or until one year following date of signature. authorization).
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