This form outlines the consent and agreement for releasing copies of the patient's medical records. For Leslie Marler.

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Ephesians Professional Counseling

Leslie J. Marler, MS, NBCC, LCPC

State Licensed Clinical Professional Counselor, National Board Certified Counselor

CONSENT TO RELEASE CLINICAL INFORMATION

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Client Information

Please fill in this section with the Client's information.

Name*
Birthday*
Address*

Release of Information

I hereby authorize the release of the following clinical information about me (or about my child or ward) TO and/or FROM Leslie J. Marler, MS, NBCC, LCPC by verbal or written means. E-mailing clinical information is prohibited.

Select all that apply
 
List any other forms of information which are authorized for release with this form.

Organization or person with whom Leslie J. Marler, MS, NBCC, LCPC will communicate:

Address
  • I understand that Leslie J. Marler, MS, NBCC, LCPC cannot be held responsible for re-disclosure of protected health information once it has been released to another party.
  • I understand that I may revoke or terminate this authorization by submitting a written request to Leslie J. Marler, MS, NBCC, LCPC otherwise this authorization will be effective for 2 years from the date of signature.
Person signing*
I acknowledge that I am 18 years old or have legal authority to sign for the Client*
MM slash DD slash YYYY
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