As the person signing this consent, I understand that I am giving my permission to the above-named person/agency for disclosure of protected health information as defined under the Health Insurance Portability and Accountability Act (HIPAA). I understand that once my protected health information is used/disclosed pursuant to this authorization, the information may no longer be protected by the privacy regulations and may be subject to redisclosure by the recipient(s). I understand that I have the right to revoke this authorization at any time. My revocation must be in writing. I am aware that my revocation is not effective to the extent that I have authorized the use and/or disclosure of my health information and such use and/or disclosure has already occurred. I may inspect or obtain a copy of the health information that I am being asked to allow the use or disclosure of. Persons/agencies who request information under this release may use a copy or facsimile of this form in place of the original signed authorization form. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment from Capstone Behavioral Health