General Consent

I authorize JP Counseling & Associates, LLC to disclose to:
Name to Release to:*
First Last
Please enter the name of the person/entity to receive your information here.
Release Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Please enter the address of the person/entity to receive your information here.
Phone*
The following information:*
- Clinical Record
- Dates of Service
- Other
If you answered "other" above, please clarify below:
For the purpose of:*
- Billing & Authorization
- Coordination of Care
- Other
If you answered "other" above, please clarify below:
I, the undersigned, understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it. This consent shall expire one year after the date of signature. I have read and understand the above information and give my consent.
I consent to the specific release of information regarding Substance Use Disorder.
I consent.
Date
MM slash DD slash YYYY
Patient Name
First Last
Patient Signature*
Authentication Code*
Parent Name
First Last
Date
MM slash DD slash YYYY
Parent Signature (if required)
Witness Name
First Last
Date
MM slash DD slash YYYY
Witness Signature*
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