I understand that I have a right to revoke this authorization at any time by sending written notification to Deaton & Deaton Counseling & Consulting, LLC, at 1100 US 127 S Suite C4 Frankfort, KY 40601. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.

Unless sooner revoked, this authorization expires on the following date: one year from current date

I further understand that Deaton & Deaton Counseling & Consulting, LLC will not condition my treatment on whether I give authorization for the requested disclosure.

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.

I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization may be redisclosed by the recipient and the protected health information will no longer be protected by the HIPAA privacy regulations, unless a State law applies that is more strict than HIPAA and provides additional privacy protections.I will be given a copy of this authorization for my records.