Please note that this authorization does not include permission to release outpatient Psychotherapy notes, unless selected in the section above.
I, the undersigned, understand there may be a cost for records to be released to me or my representative. Benhaven may also charge lawyers/law firms seeking your records depending on the reason for the records. There is no charge for
sending records to other healthcare providers or Social Security Administration.
I, the undersigned, authorize Benhaven Counseling 2 LLC to release/accept my health information as listed above.
understand and acknowledge that the requested information may contain information regarding physical and mental illness, HIV/AIDS diagnoses and treatment and/or my alcohol or drug abuse history. This authorization will expire 1 year from the date of this sign form, unless revoked by me or my legal representative.