Whiting & Associates LLC
Individual, Child, Adolescent & Adult Treatment
632 SE 4th Street (816)554-7750Lee's Summit, MO 64063
Authorization for Release of Information
to release to and/or furnish the following information from my records to the above named person, firm, clinic, school, hospital or social agency:
I hereby release the above named party from any liability for information furnished pursuant to this authorization. This release remains valid for the duration of treatment period, if not specifically invalidated earlier, of the above named patient and photo static copies of this authorization will be considered original.
THIS CONSENT TO DISCLOSE INFORMATION FROM MY RECORDS MAY BE REVOKED BY ME. IN WRITING, AT ANY TIME UNLESS THE INFORMATION HAS ALREADY BEEN RELEASED. THIS CONSENT WILL BE VALID FOR ONE YEAR FROM THE DATE OF MY SIGNING. PROHIBITION OF REDISCLOSURE: THIS INFORMATION IS CONFIDENTIAL AND PROTECTED BY FEDERAL LAW 42CFH PART 2 WHICH PROHIBITS YOU FROM MAKING ANY FURTHER DISCLOSURE OF THIS INFORMATION EXCEPT WITH THE SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS.
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