Mark Zauss - consent form between two provider - MARK ZAUSS - THERAPY

MARK ZAUSS - THERAPY

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Reciprocal Consent form

Mark is accepting new patients and accepts self pay or the insurance listed below. All sessions are confidential.

Phone: ‪(407) 734-1008‬
Email: [email protected]

Double Board Certified Counseling Services, Inc.

Mark Zauss, LMHC, LPC, CCMHC, NBCC, BC-TMC, ASDCS, NATC, CCTP, ADHD-CCSP, C-DBT Licensed in Florida, Massachusetts, and Connecticut | Phone: (407) 734-1008 | Email: [email protected]

Reciprocal Release of Information / Authorization for Communication Between Providers

Patient Information

Patient Name

Date of Birth

Phone Number

I authorize reciprocal communication and exchange of relevant medical and mental health information between the following professionals for coordinated care, diagnosis, and treatment planning.

Provider 1

Name

Mark Zauss, LMHC, LPC, CCMHC, NBCC, BC-TMC, ASDCS, NATC, CCTP, ADHD-CCSP, C-DBT

Practice Name

Double Board Certified Counseling Services, Inc.

License #

Florida: MH10977, Connecticut: 006894, Massachusetts: LMHC10000473

Phone

(407) 734-1008

Fax/Email

Email: [email protected]

Provider 2

Name

Practice Name

Address

Phone

Fax/Email

Purpose of Disclosure

Coordination of care

Continuity of treatment

Case consultation

Other

If “Other,” specify

Information to be Exchanged (check all that apply)

Treatment summaries / progress notes

Diagnostic impressions

Medication information

Assessment or testing results

Hospital or medical records

Other

If “Other,” specify

Duration & Patient Rights

Duration of Authorization: This authorization shall remain in effect for one (1) year from the date of signature, unless revoked in writing by the patient or their legal guardian.

Patient Rights: I understand that I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance upon it. I understand that information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations (45 CFR Parts 160–164).

Signatures (Typed Electronic Signature)

By typing your full name below, you acknowledge that this constitutes your electronic signature. The current date is automatically filled in and will appear on the printed copy.

Patient / Legal Guardian (Typed Name) Date

Witness (if required) (Typed Name) Date

Provider 1 (Typed Name) Date

Provider 2 (Typed Name) Date

Notice: This in-browser form is intended for completion and printing only. Do not submit protected health information through unencrypted web forms or email. For secure electronic transmission, use a HIPAA-compliant method (e.g., secure fax or encrypted portal).

Home
Credentials
Adult ADHD Assessment and Diagnosis
OCD
Anxiety
AUD
Bipolar
Autism
CBT and DBT
Narcissistic Abuse
Post-Concussion Syndrome
Chronic Fatigue, Fibromylagia & MS
Insurance
Contact