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Forms

Authorization Form -
Protected Health Information (128K PDF) Download and complete this form to approve the release of your protected health information to a person or entity of your choice.

Authorization Form -
Psychotherapy Notes (139K PDF) Download and complete this form to approve the release of your psychotherapy notes to a person or entity of your choice.

Authorization Revocation Form (179K PDF) Download and complete this form to revoke your prior authorization release.

Access Form (134K PDF) Download and complete this form to request access to specific information that we maintain about you.

Amendment Form (95K PDF) Download and complete this form to request an amendment of the information we maintain about you.

Restriction Request Form (101K PDF) Download and complete this form to request restrictions on the way in which we use or disclose your health information.

Confidential Communications Form (117K PDF) Download and complete this form to request that we use an alternative address or communication mechanism.

Confidential Communications Revocation Form (45K PDF) Download and complete this form to revoke your prior request for confidential communications.

Accounting of Disclosures Form (98K PDF) Download and complete this form to request a listing of the specific disclosures that we have made to others of your health information.

Privacy Complaint Form (107K PDF) Download and complete this document if you wish to make a complaint about our privacy practices or our compliance with our Notice of Privacy Practices. Alternatively, you can call our Privacy Complaint Line at 1-800-552-8278 or file your complaint directly with the Office for Civil Rights at the following address:

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