Authorize Behavia Therapy to release, obtain, or exchange information for coordination of care. Fill out the required fields, sign electronically (type your name or draw), and submit.
Authorizing more than one person or organization? Please submit a separate form for each recipient so each release is clearly scoped.
If no date is specified, this authorization will expire one year from the date of signature.
You have the right to revoke this authorization at any time by submitting a written request to Behavia Therapy, except to the extent that action has already been taken in reliance on it. Your treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this form. Information disclosed may be subject to re-disclosure by the recipient and no longer protected by HIPAA.
By signing below, I acknowledge that I have read and understand this authorization. I understand that the information released may include health information protected under HIPAA and that it will be shared only with the parties I have identified for purposes of coordinating care. I also understand that this authorization is voluntary and that I may revoke it in writing at any time, except to the extent that action has already been taken in reliance on it.
Your typed name becomes your electronic signature.
No mobile information will be shared with third parties or affiliates for marketing or promotional purposes. View our Privacy Policy and Terms of Use.