• Aubrey K. Ewing, Ph.D. & Associates, P.A.
    1230 So. Federal Hwy., Boynton Beach, FL 33435
    561.742-7122 | Fax 561.742.7452
    Email: contact@drewingonline.com

     

    PERMISSION TO RELEASE PROTECTED HEALTH INFORMATION

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  • I hereby release Aubrey K. Ewing, Ph.D. & Associates, P.A. and all others named above from any and all legal liability that may arise from the release of the identified protected health information. I understand that any disclosure is bound by Tile 42 of the Code Federal Regulations (chemical abuse/addiction clients), Florida Statues 294.459 (9b) and/or 90.53, 490, and 491 (psychiatric/psychological information), and the Health Insurance Portability and Accountability Act (HIPAA), and that re-disclosure of this information without my additional written authorization is prohibited.

    I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance upon it. I certify that I have read the information above and that I understand and agree to its content.

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