I understand that I have the right to revoke this authorization, in writing, at any time by sending notice to Kentucky Counseling Center, LLC. I understand that a revocation is not valid to the extent that Kentucky Counseling Center, LLC has acted in reliance on such authorization. A copy of this release shall have the same force and effect as the original.
NOTICE TO RECEIVING PARTY: You may not re-disclose any of this information unless the person who consented to this disclosure specifically consents to such re-disclosure.
I understand that there is a potential for disclosure of this information by the recipient, and if that occurs, federal law may not protect the information.