2204 Pacific Ave North Long Beach, WA 98631 Phone: 350-642-3787 Fax: 360-642-2096
Cliem:
Client
PO Box 65 South Bend, WA 98586 Phone: 360-942-2303 Fax: 350-942-5312
AUTHORIZED TO USE AND DISCLOSE PROTECTED HEALTH INOFRMATION
DOB: -----SSN: ---------------(Full Legal Name)
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SECTION A: I AU1HORIZB WII..LAPABEHAVIORAL HEALm TO USE AND DISCLOSE · PROTECTEJ? HEALTH INFORMATION (PEI) . lNITIALED BELOW . TO: .
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Prim Name of Parson/0:-g;mizatiC>ll(s) receiving the illforma±ion Address:
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Telephooe: _____________ F=·------------
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RELEASE RECORDS: . · (To agf:DCY or person listed above) Written Verbal . Clicm Initials
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OBTAIN RECORDS: (From a.,oeocy or pe:rson listed above) Verbal Written
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Intako Evalna:tion/Diagnosis Psychiatric Evaluation Medica:f:ion Records Medical Treatment ,. LabRl,pora Trcatrrlont Plan
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□ Sect:lbr yocr Iufomiation cmly
Clicm !nitiah
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Dischar� Smnma:iy Alcohol/Drag ldeD.ti:ty, diagnosis, prognosis, � by federally ftmde,d program EIV (,;\ids virus), sexually transmitted disease treatment identi1y, diagnosis, prognosis, trea±ment mformation. Progress Notos: Psychiatrist; N=e, Clinician, Group Notes Other.
SECTION B: THE PURPOSE/NEED for the above infomi.a:tion e:xc:han,,,oe is: Clie:m Iaitials To Plan/Coordinam Treatment, payme,IJ± or Health Care Opeil!ti.ons Employment A.ssistmice Monitor LR.A/Probation Legal Disclosure to a third party Af& request of the clicm, who elecfl! DOt1D disclose pmposc. Note: This box may NOT be checked ff the information to be used or disclosed pertains to alcohol or drug abuse identity, diagnosis,
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