Consent for Release of Information

Consent for Release of Confidential Information

Consent for Confidential Information

                                Howard K. Gurr, Ph.D.



(631) 462 2467  

(631) 780-4877



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.

Responsible Party Information