2130 Grand Ave.Suite B Des Moines, IA 50312 Phone: 515-270-0280

In the interest of integrative health care (which is meant to provide you or your child the best possible overall care), it is often important that your primary care provider (e.g., family doctor, pediatrician) be able to access your records. In addition, if you have a psychiatrist, it is important to be able to coordinate with him or her. Please indicate your desires below. One form must be completed for every individual/agency for whom you wish to release information. Additional forms can be provided as needed.

I understand I have the right to inspect any written information released through this authorization and such an inspection, if requested, will occur in a meeting.

I understand I may revoke this authorization by providing written notice of revocation. I also understand any information released prior to the revocation may be used for the purpose listed above.

I understand I do not have to sign this authorization. Treatment, payment, enrollment, or eligibility for benefits cannot be conditioned upon the signing of this authorization.

I understand if the person or organization that receives my information (described above) is not a health care provider or health insurer the information may no longer be protected by federal or state privacy regulations (e.g., HIPAA and other privacy regulations).

I understand and agree that a copy of this authorization (including electronic copy, fax, or photocopy) shall have the same force as the original.

NOTICE TO PERSON/AGENCY RECEIVING MENTAL HEALTH INFORMATION: The mental health information disclosed herein has been disclosed, and may only be redisclosed, pursuant to the written authorization of the client or the client’s legal representation or as otherwise provided in Chapter 228, Code of Iowa. Any unauthorized redisclosure of mental health information is unlawful and is subject to civil and criminal penalties.