Authorization for Use or Disclosure of Protected Health Information

Please correct the errors described below.

Client Information

Recipient Information

authorize Forever Hope Counseling & Educational Services, LLC to release a copy of my mental health information to the person or facility below.

Information to be Released

(Note: If you need a copy of your record, please contact the office to request a record release form.)

I intend for this Authorization to remain in full force and effect until I revoke it in writing. Further, it is my intent that a copy of this Authorization shall have the same effect as the original.

I further understand that I may revoke this authorization at any time by notifying Forever Hope Counseling & Educational Services, LLC in writing at 1162 E. Sonterra Blvd, Suite 130, San Antonio, TX 78258. I also understand that the written revocation must be signed and dated with a date that is late than the date on this authorization. The revocation will not affect any actions taken before the receipt of the written revocation.

Authorization and Signature

By typing name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

If signed by a personal representative:

Your information will be encrypted.

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