Request for Release of Information
Upon receipt of your request, an authorization for release of information form will be sent to you for your signature prior to information being released. In case I need to clarify your request, I will contact you by phone to discuss your request further.
If you have concerns about confidentiality with respect to emailing me your information request, please fax your request to my HIPAA compliant fax at 888-975-9152. Please include in your fax: your name, phone number, information you are requesting, and where you would like your authorization form sent.
If you are a current client, you can elect to execute your release of information authorization and receive your requested information via the client portal.
*HIPAA REGULATIONS REQUIRE YOU TO BE INFORMED THAT BY COMPLETING THE CONTACT FORM AN UNENCRYPTED EMAIL WILL BE GENERATED TO A PRIVATE EMAIL ACCOUNT WITH THE INFORMATION YOU HAVE PROVIDED.
PLEASE BE AWARE THAT THERE ARE INHERENT RISKS TO CONFIDENTIALITY WHEN CORRESPONDING BY EMAIL AND BY SUBMITTING THIS FORM, YOU ARE ACKNOWLEDGING THAT YOU ARE AWARE OF SUCH RISKS AND HAVE ELECTED TO ALLOW US TO COMMUNICATE VIA EMAIL.