Email Address

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:

Name of Person/Organization

If self, please complete with your own information

Email Address

No information will be shared or communicated via email unless this is provided

If "other" checked above, describe reason for release below

If "other" box is checked, this field must be completed for form to be processed

If "other" checked above, describe reason for release below

If "other" box is checked, this field must be completed for form to be processed

Revoking Authorization:
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.

Release of Information