I understand that this authorization will remain in effect for one (1) year, but I may revoke it at any time in writing. I further understand that any such revocation will not apply to any information already released/exchanged pursuant to this authorization. I understand that I am not under any obligation to sign this authorization and that my ability to obtain treatment from FLCES or any entity affiliated with Florida Counseling and Evaluation Services will not depend in any manner on whether or not I sign this authorization.
I understand that I may obtain a copy of this authorization. I understand that the disclosing entity or person may charge me reasonable cost-based fees for any record it releases pursuant to this authorization, including records requested for my own personal use. The disclosing entity/person may waive such fees for records provided to another health care provider for continuing care.
I understand that although federal or state law may prohibit the recipient from re-disclosing information provided pursuant to this authorization, the disclosing entity/person may not have any control over the recipient, and, therefore, cannot guarantee that the recipient will not re-disclose such information. I hereby release the disclosing entity or its respective representatives and affiliates from any and all liability related to (a) the reliance upon this authorization, or (b) the release of information pursuant to this authorization.
By signing below, I understand this authorization form in its entirety and have been provided with the opportunity to ask my health care provider or its representative or affiliates for additional clarification. I authorize the person or entity named above to release health care related information about me as described above. I agree that a signed photocopy in lieu of this original may serve as a valid release-of-information form.