I understand that Full Spectrum Behavior Analysis, LLC cannot guarantee that the Recipient will not re- disclose my health information to a third party. The Recipient may not be subject to federal laws governing privacy of health information.
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain treatment from Full Spectrum Behavior Analysis, LLC.
I understand that I may revoke this Authorization in writing at any time, however, I cannot revoke authorization for action that has already been taken. I further understand that I must provide any notice of revocation in writing to the Business Office at the address listed above.
A copy of this release shall be valid as the original.
THIS CONSENT EXPIRES ONE YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.