Virtual Release - Long Island EMDR

HIPAA Release

First Name

Last Name

Authorized Parties (add all that apply)

Name/Organization	Address	Phone Number

By checking this box, you authorize Long Island EMDR to discuss your health information with the authorized parties listed above.

Are you signing for yourself, or on behalf of a patient?

I'm signing this form myself.

I'm signing on behalf of someone else

Your First Name

Your Last Name

Today's Date

Virtual HIPAA Release