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Patient Name
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Date of Birth
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I authorize the disclosure of information between: Your Vision Achieved, aka YVA 1705 Southcross Drive W, Suite 101 Burnsville MN 55306 and (please fill out following): Name of Provider; Agency, Address, Phone, Fax
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I authorize the disclosures of information between above mentioned parties (please checkbox which of the following information you would like exchanged between clinics):
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Acknowledgement of Patient's access of service
Progress Notes
Mental Health Diagnostic Assessment
Progress in treatment and compliance
Discharge summary
Coordination of care
Guardian Scheduling only
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Psychological assessment/evaluation testing
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