HIPAA FormsClick on the form title(s) listed below and print. Once completed submit form to the Counseling Center in person, or by mail, email or fax.
The Counseling Center 8598 Hartman Road Wadsworth, OH 44281 Phone: 234-217-8589 Fax: 234-217-8590 Email: info@tccwadsworth.org |
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Request for Access to Health Information
Request for Amendment to Health Information
Request to Restrict Confidential Communication
Request to Restrict Use & Disclosure of Health Information
Request for Amendment to Health Information
Request to Restrict Confidential Communication
Request to Restrict Use & Disclosure of Health Information
For more information please contact: |
Diane S. DeRue, MPA, LSW
Vice President/Chief of Recovery Services Corporate Compliance and Privacy Officer (330) 264-9029 dsderue@ccwhc.org |
