I authorize, Karen Louise Scheuner, MA, RD to discuss my treatment progress with, obtain medical records or progress notes from, and release medical records or progress notes to the following:
Please check all that apply
Client Signature - I understand that my records and treatment are confidential and will not be disclosed without my written consent unless under legal compulsion. I also understand that I may revoke this consent at any time, except to the extent that action has been taken in reliance therein *
Client Signature - I understand that my records and treatment are confidential and will not be disclosed without my written consent unless under legal compulsion. I also understand that I may revoke this consent at any time, except to the extent that action has been taken in reliance therein
Entering your name here is equivalent to your digital signature. Sign by Parent/Guardian if under 18.
Date
Date
Revoking Consent
I hereby revoke my consent:
I hereby revoke my consent:
Entering your name here is equivalent to your digital signature. By doing so, you revoke consent to release information.
Date
Date