I hereby release Aubrey K. Ewing, Ph.D. & Associates, P.A. and all others named above from any and all legal liability that may arise from the release of the identified protected health information. I understand that any disclosure is bound by Tile 42 of the Code Federal Regulations (chemical abuse/addiction clients), Florida Statues 294.459 (9b) and/or 90.53, 490, and 491 (psychiatric/psychological information), and the Health Insurance Portability and Accountability Act (HIPAA), and that re-disclosure of this information without my additional written authorization is prohibited.
I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance upon it. I certify that I have read the information above and that I understand and agree to its content.