Authorization to Release Protected Health Information (PHI) Form

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.