We keep your Protected Health Information private and secure. This consent form is to gain permission to share administrative information like appointment reminders, scheduling, or payment receipts with you. Please understand that some potential risks associated with email/text interaction include: misdelivery, unauthorized access to thirdpartes, information may remain in the cloud. Please indicate your preferences about emails and texts and sign this form.
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This form is to give us permission to communicate with third parties. The content and information to be released is protected under State and Federal law (45 CFR Part 164 and 164; 42 CFR Part 2) and cannot be re-disclosed without further written consent as authorized by G.S. 122C-53 through G.S. 122C-56. A general authorization for the release of other medical information is not sufficient for this purpose. More details can be found in our Privacy Practice form.
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We ask you to provide formal authorization to process credit card payments. Please verify and complete this form to give Wilmington Mental Health to do so. Do not omit any fields and include your signature and today’s date at the end.

A picture ID (school ID, military ID, etc.) is required for all patients 18-year-old and older to protect you and our practice against insurance fraud.

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