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BILLING INFORMATION

Client:

Date Of Birth:

I authorize the use and disclosure of billing information as described below; and,

Authorize and request Paraclete Ministry Group LLC, dba MyCounselor

TO RELEASE AND/OR MUTUALLY SHARE THE FOLLOWING INFORMATION: any and all billing records

Covering all past, present, and future periods of care.

The requested information is to be released by/to and/or mutually shared with:

The requested information is to be used or disclosed for the purpose of providing better service to said client

This authorization shall be in force until I exercise my right of revocation, as described below,

I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so by communicating in writing, with specific reference to this authorization, to MyCounselor.Online. I understand that the revocation will not apply to information that has already been released in response to this authorization.

I understand that I may refuse to sign this authorization.

I understand that after information is disclosed pursuant to this authorization, it is possible that the information may be redisclosed by the recipient and would no longer be protected by applicable medical privacy laws.

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Timestamp

Audit

May 30, 2024 11:11 am MDT

AUTHORIZATION TO USE AND DISCLOSE BILLING INFORMATION Uploaded by Josh Spurlock - josh.spurlock@mycounselor.online IP 70.174.52.34

May 30, 2024 1:47 pm MDT

Intake Forms - New_Int.tdri2xkn3ohkvw4m@u.box.com added by Josh Spurlock - josh.spurlock@mycounselor.online as a CC'd Recipient Ip: 70.174.52.34