Consent for Release of Information

Consent for Confidential Information

                                Howard K. Gurr, Ph.D.

                                            Psychologist

 

2631 MERRICK ROAD, SUITE 205

 

2 CORWIN COURT

BELLMORE, NEW YORK 11710

 

DIX HILLS, NEW YORK 11746

(516) 785-3834

 

(631) 462-2467

Website-www.drsgurr.com

www.vrtforphobias.com

        E-Mail hgurr@drsgurr.com

 

       Fax    (631) 462-0745

 

 

 I am agreeing to allow Dr. Howard Gurr to communicate, or share information, about myself or my child with  the Practitioners indicated on this form. I understand that I have no obligation whatsoever to disclose the requested information and that I may revoke this consent at any time by informing in writing any of the identified individuals. I further understand that this authorization is valid for a period of 90 days from the date of my signature below.

In consideration of this consent, I hereby release the listed parties from any legal liability resulting from the release of this information.

I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule.



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