In agreeing to sign this Consent, I understand:
Information disclosed pursuant to this Consent may be re-disclosed by the Recipient. Such disclosure may no longer be protected by state or federal confidentiality and privacy laws.
I may refuse to sign this Consent. Signing this Consent form is voluntary and refusing to sign it will not prohibit you from receiving services from any of the above Recipients. Mark this box if you do not give permission for your health information to be shared with the above Recipients.
I may revoke this consent at any time, except to the extent that action has already been taken in reliance on this Consent, and I must do so in writing. Acting in reliance includes the provision of treatment services in reliance on a valid consent to disclose information to a third party payer. If Consent is revoked, the Recipients identified above shall not be required to recall information already shared.