Client/ Patient Information
Information of person or entity receiving records
I have had the full opportunity to read and consider the contents of this authorization. I understand that by signing this form, I am confirming my authorization for the use and or disclosure of my protected health information, as described in this form.
*Please note that medical records are retained for 10 years, and therapy/counseling records retained for 8 years.
**Records requested by other like providers will be exempt from fees. Records requested for all other purposes will be charged the following fees: - Clerical Fee $28.00 - First 30 Pages $0.20Per Page - After 30 Pages $0.10