HIPAA Authorization – MCL Counseling & Hypnosis

This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone # / Cell #

My Authorization

I authorize the following parties to exchange my health and well being information covering the period from

from

Michele Maltais, Nutritional Lifestyle Coaching

Michael Landgren. LICSW, MCL Counseling and Hypnosis

I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original. I understand that I may revoke this authorization at any time and must do so in writing to Michele Maltais, Nutritional Lifestyle Coaching.

Name *

First

Last

Date