||The Following information: Diagnostic and treatment information
This information is needed for the purpose of coordination of care and on-going evaluation by telephone,
facsimile, written documentation or meetings if indicated.
I understand that the agency abides by Federal Confidentiality Regulations (42 CFR, Part 2) published
July 1, 1975, which protect the confidentiality of my records and that information contained in my
record cannot be disclosed without consent unless otherwise provided for in the regulations.
I understand that this directive is subject to revocation at any time upon written request. Otherwise this
consent will expire upon one year from date signed.
I herewith release and hold harmless Elisa Elkin-Cleary, LICSW, from any liability for the release of any
information provided in accordance with this directive.