• Release of Information

    Lisa Inoue LMSW PLLC
  • By signing this form, I authorize Lisa Inoue, LMSW to disclose information about myself or my minor child to the person or entity specified below.

  • The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services.

  • Description of Information to be Disclosed

    Check each box that you agree to:

  • Expiration

  • This authorization will automatically expire on the day of discharge from treatment. If you wish to specify a different expiration date, please provide it below.

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  • Acknowledgements

    • I understand that I have a right to revoke this authorization at any time by notifying Lisa Inoue, LMSW, PLLC verbally or in writing. I further understand that any revocation will not apply to information that has already been disclosed.
    • Unless I have specifically requested that the disclosure be made in a certain format, Lisa Inoue LMSW PLLC reserves the right to disclose information as permitted by this authorization in any manner deemed to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.
    • I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization may be redisclosed by the recipient and the protected health information will no longer be protected by the HIPAA privacy regulations, unless a State law applies that is more strict than HIPAA and provides additional privacy protections.
    • If I request it, I will be given a copy of this form for my records.
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  • Clear
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