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I hereby authorize Britteny Asher Consulting and Associates to request, share and/or exchange information with the following individuals / service providers / agencies. Information to be shared is deemed relevant to collaborate and or provide services including evaluation, treatment and billing.
I understand the records are protected under the federal and state confidentiality regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time.
I also understand if I choose not to authorize disclosure of information needed for Britteny Asher Consulting to preform evaluations and or services, services provided by Britteny Asher Consulting may be limited, or refused.
This form will securely submitted to Britteny Asher Consulting.
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