Release of Information Disclosure Form

Release of Information Disclosure Statement

Please fill in the form below
Person/organization disclosing information: PPCC Inc. and/or your therapist will be disclosing information pertaining to your treatment. Your information may be faxed, mailed, or emailed to the organization or person you designate to receive this information.
Person/organization receiving information *
Enter the name and organization receiving the information
Client Name *

First Name Middle Name Last Name Suffix
Specific information disclosed *
Enter the specific information to be disclosed
Purpose or need for disclosure *
Enter the purpose or need for the disclosure
This consent to disclose the above information is subject to revocation at any time, and unless revocation is expressed otherwise, the consent expires in one year from the date of the request.

Month Day Year
Enter the date the consent expires if sooner than one year.
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
Signature of Client / Guardian *

Sign this document agreeing to the disclosure of the information Clear
Today's Date *

Month Day Year
Date
If Guardian signed, please input your relationship to the client
Guardian, enter your relationship to the client
Should be Empty:

Release of Information Disclosure Statement