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 Google 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.