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Release of Information

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RELEASE OF INFORMATION

Authorization for Release of Protected Health Information

RELEASE OF INFORMATION FORM

I hereby authorize Farratti Psychiatry to disclose and/or obtain my protected health information as described below.

Person/Organization releasing information

Name:

Farratti Psychiatry

I understand that:


• I may revoke this authorization in writing at any time, except to the extent action has already been taken.

• Information disclosed may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA.

• Refusal to sign will not affect my ability to obtain treatment.

Or


Download and Fill the Relase of Information Form

Farratti_Psychiatry_Release_of_Information
Farratti Psychiatry – Your Path to Mental Wellness