• Release of Confidential Records and Information

    BreakThrough Counseling Services, LLC.
  • I,   *   *, hereby authorize the release of my own confidential patient health information (PHI).

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  • Permission is granted for: * to:
     at the following address:             .
      at the following address:               .
      at the following telephone number:       

  • I have had explained to me and fully understand the request/authorization to release records and information, including the nature of records, their contents, and the consequences and implications of their release. This request is entirely voluntary on my part. I understand that I may take back this consent at any time within 180 days, except to extent that action based on this consent has already been taken. This consent will expire automatically after 180 days from the date on which it is signed, or upon fulfillment of the purpose stated above.

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