whose Date of Birth is:
and whose email is:
authorize LifeSolutions Counseling Associates, P.C. to disclose to and/or obtain from:
the following Information to be Disclosed:
Revocation: I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to LifeSolutions Counseling at 1185 W. Carmel Dr., STE D4, Carmel, IN 46032. I further understand that a revocation of the authorization is not effective to the
extent that action has been taken in reliance on the authorization.
Expiration: Unless sooner revoked, this authorization expires on the following date:
or as otherwise indicated:
Conditions: I further understand that LifeSolutions Counseling Associates, P.C. will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences:
Form of Disclosure: Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.
Redisclosure: I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization may be redisclosed by the recipient and the protected health information will no longer be protected by the HIPAA privacy regulations, unless a State law applies that is more strict than HIPAA and provides additional privacy protections. I will be given a copy of this authorization for my records, if requested.
I will be given a copy of this authorization for my records, if requested.
LifeSolutions provides professional services that will help improve your mind, spirit, and wellness in life.
Call (317) 569-5433 Today.
We’re Here To Help.
Old Meridian Professional Center1185 W. Carmel DriveSuite D-4Carmel, IN 46032(317) 569-5433
Riverview Medical Arts14540 Prairie LakesBoulevard North Suite 202Noblesville, IN 46060(317) 569-5433
Beginning April 19, 2021, all client information, forms, and balances can be viewed from a New Client Portal. You will receive access to this New Client Portal via two emails, one providing you with your user name and one providing you with a temporary password and a link to the New Client Portal. Please contact support staff with any questions at 317-569-5433.