FIRST NAME
LAST NAME
TO ADDRESS

(TO:)

RELEASING ORGANIZATION NAME
TO PHONE NUMBER
TO FAX NUMBER

Type of Release:

This information is considered instrumental to the ongoing evaluation and professional treatment of the client or has been directly requested by the client to be released.

Thank you for taking the time to fill out these information sheets! The information requested on these forms are MANDATORY for all claims submitted to insurance carriers.

(FROM:)

6550 South 84th St., Suite 300, Omaha, NE  68127

Select your counselor:

 "My full legal name will act as my signature."

AUTHORIZATION FOR RELEASE OF INFORMATION

Click this box for a checkmark to indicate "Yes I grant authorization"

Disclosure and release of any information regarding the above-named individual.

"I understand that this release of information is intended to allow me to provide my informed consent for an exception to my confidentiality and the protection of my privacy guaranteed under federal law, including but not limited to the Privacy Act of 1974 (PL 93-578), the Freedom of Information Act of 1974 (PL 93-502), the Code of Federal Regulations 42, Part 2, and the Health Insurance Portability and Accountability Act (HIPPA)."

information
release

REQUIRED: Please enter your first and last name to complete the assessment.

LAST NAME

*

FIRST NAME

*

*

All information sent is held as strictly confidential. 

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