• Authorization to Use or Disclose Protected Health Information

    (Required by the Health insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
  • Release Information to the Following

  • By signing below, I am authorizing Kate Walker, LCSW to use and disclose my protected health information for the purposes of directing treatment and/or consultation or other purposes as I may direct 

    This authorization shall be in effect for one year from the date of the signature below unless otherwise expressed.

    I understand I have the right to revoke this authorization, in writing, at any time. 

    I understand that my treatment will not be conditioned on whether I sign this authorization.

    I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

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