The Counseling Center - Wadsworth Office
(234) 217-8589
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HIPAA Forms

Click 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

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
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​The Counseling Center
​8598 Hartman Road
Wadsworth, OH 44281

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