This is the YLW HIPAA acknowledgment form. Please review carefully. You can find information about how YLW is allowed to use your personal health information and how you can request your records. You may need to copy and paste this to a word doc and fill it out
This is an authorization and information provided to clients who are having counseling services with an LPC Associate. You may need to copy and paste this to a word doc and fill it out .
ALL CLIENTS MUST HAVE ONE FILLED OUT. IF THE CLIENT IS A MINOR THEN THE PT. NAME AND INFO IS THE CHILD AND THE SIGNATURE AND INITIALS ARE THE PARENTS.
This form may be needed to release information to a third party. You may also request copies of your own records with this form. Will be requested if needed.
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