AUTHORIZATION TO USE AND/OR DISCLOSE HEALTH INFORMATION
I authorize Seattle Christian Counseling to use or disclose my health information as described below.
| Type of Information Disclosed | Recipient of Information | Purpose of Disclosure |
| PHI from intake form | Therapists in our network | Therapist’s intake process |
| PHI from intake form | General Business Operations and Marketing | |
| PHI from intake form | MailChimp | Marketing |
| PHI from intake form | Cognito Forms | Marketing |
| PHI from intake form | Other Business Associates | General Business Operations and Marketing |
I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the HIPAA Privacy Rule may no longer protect the information.
I understand that Seattle Christian Counseling may receive compensation related to the use or disclosure of the requested information.
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Benjamin Deu at 444 NE Ravenna Blvd. Suite 301 Seattle WA 98115. I understand that the revocation will not apply to information that has already been released in response to this authorization.
This authorization will expire upon my written revocation of authorization.