Protected Health Information obtained will be used to assist in the treatment and provision of services provided to the patient/client by EnSpire Counseling & Wellness, LLC.
▪ I understand these records may contain information concerning sexually transmitted disease(s), acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), drug abuse, substance abuse, alcoholism, sickle cell anemia, and behavior or mental health services.
▪ I understand that this authorization, except for action already taken, may be revoked by me at any time.
▪ I understand that if I revoke this authorization, I must do so in writing and present my written revocation to EnSpire Counseling & Wellness.
▪ Unless otherwise revoked, this authorization will expire one year from today's date and must post-date any date of service being requested.
▪ This authorization becomes null and void from the date entered in the chart that the chart will be closed.
▪ I understand that EnSpire Counseling & Wellness will not condition treatment, payment, enrollment, or eligibility for benefits concerning my health care on whether I sign or refuse to sign this authorization.
▪ I understand that authorizing the disclosure of this health information is completely voluntary and the disclosure of such information carries with it the potential for unauthorized re-disclosure.