Section IV: Authorization
This authorization will remain in effect until revoked or shall expire on date or event specified below. I understand that I may revoke or cancel this authorization at any time by submitting written revocation in the manner specified by the disclosing entity, except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will expire on the date or completion of the event stated below. If no date or event is specified below, this authorization will expire in one year.
I understand that I may not be denied treatment, payment, and enrollment in the health plan, or eligibility for benefits for refusing to authorize disclosure unless such denial is permitted under state and federal law.
I understand that information disclosed by this authorization, except as prohibited by 42 CFR Part 2 or other applicable law, may be subject to re-disclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act Privacy Rule (45 CFR Part 164].
Denial of request. I understand that if the disclosing entity determines that disclosure of the full records is reasonably likely to cause substantial harm to the patient or another individual, this request may be denied. If denied, I (the requestor) will be notified in writing via email within 7-10 days of the request with the reason for denial and I may choose to receive a treatment summary instead of full notes; I may meet with a therapist to review the contents of the records; or I can have the records sent to a mental health provider or physician that I designate.