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Please complete this form below to allow Dr. Segal to communicate with your other healthcare providers (i.e. therapist, pediatrician, etc.) and other people that you desire such as school or workplace about your mental healthcare.



7910 Woodmont Avenue, Suite 1101
Bethesda, MD 20814

drsegal@bethesdapsychiatryllc.com
301-615-4270

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By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.