I am the patient, or the legally authorized representative of the patient, listed above.
I request Arbor therapy Solutions, PLC, and Natasha Lewis-Grinwis, LMSW, CST or Kris Lewis-Grinwis, LMSW
to release my protected health information (or the information of the patient listed above) to:
1. I may revoke this authorization at any time.
2. Revocations must be made in writing and provided to Arbor Therapy Solutions, PLC and Natasha Lewis-Grinwis, LMSW, CST or Kris Lewis-Grinwis, LMSW via the postal service or in person.
3. Revocations will not apply to information that already has been released.
4. If this authorization was obtained as a condition of providing insurance coverage, the authorization will not apply to my insurance company to the extent the law provides my insurer with the right to contest a claim under the policy, or the policy itself.
I understand that once information has been disclosed, Arbor Therapy Solutions, PLC, Natasha Lewis-Grinwis, LMSW, CST, and Kris Lewis-Grinwis, LMSW can no longer protect it from further disclosure.