HIPPA Consent Form
 Print the HIPPA Consent Form
Stefan Schlesinger, MA, LMHC, d/b/a Global Counseling
Couple’s Counseling Center and Men’s Counseling Center Northwest
8401 5th Ave NE, Suite 103
Seattle WA 98115
206-522-8700
206-526-0444
State Licensed Mental Health Counselor #LH 00004067
Health Insurance Portability and Accountability Act (HIPAA)
Client Consent Form
Use and Disclosure of Your Protected Health Information
I consent to the use or disclosure of my protected health information (PHI) by Stefan Schlesinger, M.A. d/b/a Global Counseling for the purpose of treatment, payment and counseling business operations.
I have received a copy of the Disclosure Statement and Disclosure Form, as well as the Washington State Department of Health’s brochure for counseling clients. The combination of these forms contains the appropriate notices of privacy practices used by Stefan Schlesinger, M.A. d/b/a Global Counseling.
Service to me may be conditioned upon my consent as evidenced by my signature on this document.
My Rights as a Client
- I have the right to request a restriction as to how my PHI is used or disclosed to carry out treatment, payment or counseling business operations of the practice. Stefan Schlesinger, M.A. d/b/a Global Counseling is not required to agree to the restrictions that I may request. However, if Stefan Schlesinger, M.A. d/b/a Global Counseling agrees to a restriction that I request, the restriction is binding on Stefan Schlesinger, M.A. d/b/a Global Counseling.
- I have the right to revoke this consent, in writing, at any time, except to the extent that Stefan Schlesinger, M. A. d/b/a Global Counseling has taken action in reliance on this consent.
Right to Change Privacy Practices
Stefan Schlesinger, M.A. d/b/a Global Counseling reserves the right to modify the Disclosure Statement and Disclosure Form as needed. I will be notified of these changes in writing. All current or revised notices can be obtained by visiting the Global Counseling website at http://www.globalcounseling.org or by requesting a written copy from Stefan Schlesinger, M.A. d/b/a Global Counseling at the address and phone numbers noted above.
My Consent
I have reviewed this consent form, the Disclosure Statement, the Disclosure Form, and the Washington State Department of Health’s brochure for counseling clients. I give my permission to Stefan Schlesinger, M.A. d/b/a Global Counseling to use and disclose my health information in accordance with this consent and the notices provided.
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