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RELEASE OF INFORMATION

This form is used to request that the client's personal and protected health records with Quality Youth Services be released to a third party or to the client, or both. This form can also be used in order for a third party to share their personal and protected health records for a client with Quality Youth Services. These forms are usually signed so Quality Youth Services can speak with a third-party regarding the client. Care is made to release only what is necessary to that third party or vice versa.

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877-393-6232 
Fax: 877-393-6232
admin@qyservices.com

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Or contact us here

By calling or texting this number (877) 393-6232, customers agree to receive text messages. If you no longer wish to receive text messages, you may opt out at any time by replying "STOP".

QYS Clinical Services


2240 US-89 STE C
Harrisville, UT 84404

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1638 N 200 W STE H

Logan, UT 84341

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140 S Main St STE 1

Pleasant Grove, UT 84062

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©2021 BY QUALITY YOUTH SERVICES

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