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11161 Kenwood Rd
Cincinnati, Ohio 45242
Phone (513) 769-4600 Fax (513) 769-0304
Attn: Medical Records
I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired
immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV) and drug and alcohol abuse, drug-related conditions,
and/or alcoholism. I authorize the release or disclosure of this information.
Confidentiality will be maintained within the supervisory-counselor relationship, except when there appears to be imminent danger to
you or others. I understand this authorization may be revoked in writing or in person to Lifeway Counseling Centers at any time
except to the extent action has been taken prior to revocation.
You agree to hold LifeWay Counseling Centers, Inc. harmless from any claim or liability (including, but not limited to, any claim
brought under a confidentiality or privacy law) in connection with the release at your request of the information and records described
above. Thus, I acknowledge that the information disclosed pursuant to this authorization may be subject to re-disclosure by the
recipient and no longer protected by Federal Law.
Further, Lifeway will not condition treatment, payment, health plan enrollment and/or plan eligibility on the refusal to sign this
authorization; however information will not be released without signature.
© LifeWay Counseling Centers, Inc. All Rights Reserved.