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I authorize Arohi Counseling
Authorization to disclose or obtain confidential client information
By Signing This Form, I Understand The Following
Due To The New Federal Patient Confidentiality Laws (Hipaa)
Acknowledgment Of Our Notice Of Privacy Practices
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Due To The New Federal Patient Confidentiality Laws (Hipaa)
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Due To The New Federal Patient Confidentiality Laws (Hipaa)
Due to the new federal patient Confidentiality Laws (HIPAA) Arohi Counseling, LLC will need your permission to do the following: Circle one and then initial
CONFIRM APPOINTMENTS
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No
LEAVE MESSAGES WITH ANYONE OR ON RECORDER
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No
LEAVE LAB RESULTS WITH ANYONE OR ON RECORDER
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No
BY SIGNING THE ABOVE I FULLY UNDERSTAND THAT I AM GIVING AROHI COUNSELING, LLC AND ASSOCIATES, PERMISSION TO DO THE ABOVE.
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PATIENT NAME
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STAFF WITNESS (sending by mail N/A)
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