You may revoke this consent to disclose the above-stated information by notifying the clinician disclosing the information and the person faxing/sending the information that you no longer desire to have your health information disclosed. You may contact these individuals by calling our office or sending them a written notice of your desire to no longer have your health information released.
Please mail your written notice to:
Pattison Professional Counseling & Mediation Center
7 Vine Avenue NE
Fort Walton Beach, FL 32548