Authorization to Release Information to Salem Counseling Center -- Digital Format
This form will give a third party (another healthcare provider, clergy, family members, etc.) permission to share protected information about you with SCC for the purposes of making a referral and/or potentially coordinating future services. By completing this form digitally, you recognize that any information shared via the internet cannot be determined as 100% secure, and you assume the associated risks with sharing private information in this way. You also release Salem Counseling Center from any liability related to any security breach that could occur in the transmission of this data between the completion of this form and its receipt by SCC.
Client Information
Name *
Date of birth *
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Phone *
Email *
Address *
Who can send records, and what information may they send?
I (the client listed above) authorize the following healthcare provider: *
(Include healthcare provider or organization's name)
To disclose the following types of protected information about my treatment: *
Required
To: Salem Counseling Center, PLLC
203 S Stratford Rd, Ste A, Winston-Salem, NC 27103 (ph) 336-934-4670 (em) office@salemcounselingctr.com
For the purposes of: *
Required
I understand that I have a right to withdraw this authorization at any time. If I revoke this authorization, I must do so in writing and present my written withdrawal of authorization to the health care provider named above. I understand that the withdrawal will not apply to information that has already been released in response to this authorization. I understand that this authorization for disclosure is voluntary and that I do not need to sign this form to ensure healthcare treatment.
This authorization will expire twelve months after date of signature unless an earlier date is listed below.
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By typing my full name into the space below, I recognize that I am providing the equivalent of an electronic signature, thereby authorizing that this release of information consent form shall go into effect. *
If you would like to complete this authorization form, type your full name below.
Date *
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Typed full name (electronic signature) of parent/legal guardian if client is under 18 years old:
Date
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Submit
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