I understand that if the organization authorized to receive information is not a health plan or health care provider and if such information is re-disclosed by the recipient, the released information may no longer be protected by federal privacy regulations, but may be protected under Maryland State Law.
- I understand that this authorization is voluntary.
- I understand that the client’s health care and payment will not be affected if I do not sign this form.
- I understand that I may receive a copy of this form after I sign it and that I may inspect and request a copy of the information I am authorizing for use or disclosure.
- I understand that these records are to be kept confidential and the information is for use by that action has been taken in reliance upon it.
- I understand and agree that this release may contain information pertaining to psychiatric, drug and/or alcohol diagnosis and treatment.
- I understand that I may revoke my consent in writing at any time, except to the extent that an action has been taken in reliance upon it.