• GRUNBLATT PSYCHOLOGY AND COUNSELING OFFICES, P.C.

    Authorization Form (HIPAA)-Authorization for Disclosure of Protected Health Information
  • This authorization shall be in force and effect until one (1) year after the date below at which time this authorization to disclose protected health information shall expire.

  • I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the Practitioner at the address above. I understand that a revocation is not effective to the extent that the Practitioner has relied on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

  • I understand that information disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by HIPAA or any other federal or state law.

  • The Practitioner will not condition my treatment on whether I provide an authorization for disclosure except if health care services are provided to me solely for the purpose of creating protected health information for disclosure to a third party.

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