Authorization to Release Your Health Information
At Lumiere Du Coeur Habilitation Center, we respect your privacy and understand the importance of your health information. This form allows you to authorize the release of your Protected Health Information (PHI) to specific individuals or organizations, such as your doctors, specialists, family members, or insurance providers.
By filling out this form, you give us permission to share your health information as outlined.
Please note, this form does not include psychotherapy notes. Psychotherapy notes require a separate form, which you can find on our website.
- Important Information
- You can refuse to sign this form without affecting your care.
- You can revoke this authorization at any time by contacting our Privacy Officer.
For more information, please contact our Privacy Officer:
Aimee Williamson
Phone: 251-725-0260
Email: info@ldchc.org