• 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.

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  • 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

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