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Release of Information
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CommonSense Provider Full Name:
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Outside Provider Full Name:
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Do you authorize your provider with CommonSense to share clinical records as needed as well as verbal consultation between providers?
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Outside Provider Phone Number:
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I hereby authorize my assigned CommonSense providers and CommonSense Wellness Network (CSWN), IPA, LLC to release information as described above to, and request information from, the person or organization identified herein.
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Outside Provider E-mail:
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I understand that the person or organization named above may not be subject to the same privacy laws and regulations as my providers at CSWN as a whole, and may be able to further share the information disclosed under this authorization.
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Outside Provider Address:
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