Authorization for the release of Protected Health Information (PHI)

Send your completed release to us mail mail, fax, or *email:
*Email communications are password secure but not encrypted and may be subject to unauthorized redisclosure or hacking.

Square One Specialists in Child and Adolescent Development
6440 Dutchmans Parkway • Louisville KY 40205
(502) 896-2606 • Fax (502) 896-0487
meds@squareonemd.com

Square One Specialists in Child and Adolescent Development abides by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules.

Requests are processed within 30 days of receipt of request.