Common Contracts

CONSENT TO USE AND DISCLOSE YOUR HEALTH INFORMATION

Use and Disclose Your Health Information • March 12th, 2015

• Contract Type
  Use and Disclose Your Health Information
• Filed
  March 12th, 2015

This form is an agreement between you, , and Kristina Kops, Psy.D. When I use the word “you” below, it will mean your child, relative, or other person if you have written his or her name here: .