top of page
Patient Rights and HIPAA Authorizations

Please download and complete the attached Authorization for Use or Disclosure of Protected Health Information and email to our office at  wisnumeier@inwardjourneycounseling or bring to your first appointment.

OR COMPLETE THE ONLINE FORM BELOW

Authorization to Release Information.

Authorization to Release Information Form

Please take a moment to fill out the form.

Purpose of Infomation Relase
Personal Representaion Information - Patient is:
Personal Representative's legal authorty:

Thanks for submitting!

bottom of page