I understand this authorization remains in effect until the date of expiration. I understand this authorization may be withdrawn any time in writing (except to the extent that action has already been taken). Further release shall cease (except as allowed by law) upon Carolina Complete Psychiatry receipt of the written revocation.
At any point and time, the patient may chose to revoke access to the person(s) listed above. Should you chose to REFUSE OR REVOKE ACCESS of medical information to the person listed above, please sign here: