I further understand that TINA C. CHRISTIAN, LPC, NCC will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences: (if any)
Form of 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.
A copy of this authorization will be availble to you in your documents area of our client portal.
If you are signing as a personal representative of an individual, please describe your authority to act for this individual (parent, guardian, power of attorney, healthcare surrogate, etc.):