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  • I hereby authorize the mutual exchange of information between Aspen Leaf Holistic Mental Health and the following:
  • I understand that information to be released for the purpose of psychiatric evaluation and ongoing treatment may include information regarding the following conditioning(s): - Psychiatric Conditions, Psychological Testing, Progress Notes, Medications Prescribed - Assessment including Diagnosis - Treatment Summary, Recommendations, Consultation - Drug and/or Alcohol Abuse - Medical Information - HIV (Human Immunodeficiency Virus)/AIDS (Acquired Immunodeficiency Syndrome) - Educational Information I understand that I may revoke this consent to release medical information at any time by giving written notice to Aspen Leaf Holistic Mental Health except to the extent that action has already been taken to comply with it. Without such revocation, this consent is valid until treatment with Aspen Leaf Holistic Mental Health ends. I release Aspen Leaf Holistic Mental Health from all legal responsibility and liability for the information released according to the terms of this written consent. I understand that there is the potential for this protected health information to be re-disclosed by the recipient and thus no longer protected under the HIPPA privacy rule.