HIPAA

I acknowledge that I have been provided access to Mend the Mind’s Notice of Privacy Practices, which outlines how my protected health information (PHI) may be used or disclosed in accordance with the Health Insurance Portability and Accountability Act (HIPAA). I understand that Mend the Minds is committed to maintaining the confidentiality of my health information and will only use or disclose it for purposes of treatment, payment, or healthcare operations, unless otherwise authorized by me or required by law.

Release of Information

I hereby authorize Mend the Minds to release, obtain, and/or share my personal health information with the following individuals or organizations for the purpose of coordinating care, treatment, or related services. I understand that this consent is voluntary and can be revoked at any time by providing written notice, except where disclosure has already occurred in reliance on prior consent.

Informed Consent

I hereby acknowledge that I have been informed about the nature, purpose, and potential risks and benefits of the services provided by Mend the Minds. I understand that participation in therapy, counseling, or other behavioral health services is voluntary and that I have the right to ask questions, seek clarification, and discontinue services at any time without penalty.