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Tiffany Teamer | Teamer Counseling

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Health_Information_Release_Authorization_Form

July 5, 2018 by Tiffany Teamer

Health_Information_Release_Authorization_Form

389 Hooker Avenue
Poughkeepsie, NY 12603

845-206-4046
info@teamercounseling.com

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By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

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