I understand that this release is voluntary and applies to all programs and services operated under the auspices of Juniper Health & Wellness, LLC, I understand that my personally identifiable information (PHI) may be protected by the federal rules for privacy under the Family Educational Rights and
Privacy Act (FERPA), the Health Insurance Portability and Accountability Act (HIPAA), and/or applicable state or federal laws and regulations.
I understand that my PHI may be subject to re-disclosure by the recipient without the specific written consent of the person to whom it pertains, or as otherwise permitted.
I also understand that the recipient may not condition treatment, payment, enrollment, or eligibility on whether I sign this form, except for certain eligibility or enrollment determinations.
I understand that I may revoke this authorization at any time by notifying Sonya Ashley of Juniper Health & Wellness, LLC in writing but if I do it will not have any effect on any actions taken before the receipt of the revocation.