HIPPA AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION

Please correct the errors described below.

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Dialogical Therapy, PLLC, dba Open Dialogue Pacific Alita Kathryn Taylor, MA, LMFT & Fletcher Taylor, MD, MFA 2706 North Warner Street, Tacoma, WA 98407 2101 4th Ave #370, Seattle, WA 98121 Phone: 253-212-3101 FAX: 253-212-3225

HIPPA AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION

PLEASE FILL OUT ONE HIPPA AUTHORIZATION FORM FOR EACH ENTITY OR PROFESSIONAL YOU WANT US TO COMMUNICATE WITH. Email admin@dialogicaltherapy to tell us how many more HIPPA forms you would like sent to you.

(e.g., insurance company, primary care physician, hospital, treatment facility other professionals, etc.)

. *NOTE: USE ONLY ONE HIPPA FORM PER ENTITY

I recognize this information may contain sensitive data, including data related to treatment of mental health, physical or sexual abuse, alcohol/substance abuse, sexually transmitted diseases, HIV/AIDS, and reproduction or contraception (including prenatal care and abortion), and hereby consent to such disclosure. I authorize this information identified above to be disclosed to the following entity and/or person(s):

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Dialogical Therapy, PLLC 2706 N. Warner St. Tacoma, WA 98407 Phone: (253) 212-3101 Fax: (253) 212-3225

I may cancel this authorization at any time by sending written notice to the authorized entity above. Cancellation of this authorization will not affect any actions taken or disclosures made before receiving my cancellation notice. I understand completing this authorization is not a condition to receive treatment, payment, enrollment, or eligibility. I am aware that information may be re-disclosed by the recipient and that once the authorized entity above discloses my information to the recipient, the privacy protections provided by law may no longer apply. A copy of this authorization is as valid as an original.

Signature:

Please type your full name

Personal Representative

If you are signing this authorization on behalf of another individual (e.g., a minor), please complete the following and attach documentation demonstrating your authority to act on behalf of the individual (e.g., power of attorney, guardianship, conservatorship, etc.).

Please type your full name

* NOTE: I understand that my substance abuse records are protected under Federal law (42 CFR Part 2) and cannot be disclosed without my written consent unless otherwise provided for in 42 CFR Part 2. I also understand that I may cancel this approval at any time, as described above.

Your information will be encrypted.