• BRITTENY ASHER CONSULTING

  • HIPPA Consent for Release Of Information

  • If you have any questions when filling out this form, please contact Britteny Asher Consulting, we are here to help!  

  • 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.

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