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I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it e.g. the provision of treatment upon consent to disclose to third party payers. This includes but is not limited to the forms completed at the time services were initiated. Mailing Address Kimberly L. Fender MA LPC Hope Springs Counseling Services LLC PO Box 372 Lexington SC 29071 Telephone 803-470-5525 Fax 888-843-3412 CONSENT AND RELEASE I authorize the exchange of...
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