Release of Information - His Way Counseling

I hereby give my permission for:

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To release or disclose to:

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The purpose or need for disclosure is:(Required)

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The information concerns the care given to:

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This consent is subject to revocation at any time in the form of written notice from myself, except to the extent that action has been taken in reliance thereon, or without revocation, will expire one year from the date signed below.

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You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (800) 985-3059.

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