I understand that my signature on this form is voluntary and that not signing will not affect the ability to receive treatment at this practice. I understand that this release will expire in 180 days, unless revoked by me which I have the right to do at any time. I understand that any revocation will not apply to any PHI that has already been released in reliance to this authorization and to PHI created expressly for disclosure to the person/entity listed below. I understand that the PHI disclosed may be subject to re- disclosure by the person/entity receiving it and no longer protected by federal privacy regulations except in the case of drug/alcohol treatment which must be clearly stamped "Do not re-disclose" and protected accordingly under 42 CFR part 2. I understand that any questions I have about the use or disclosure of this PHI can be directed to this practice at any time.
I give permission for Beacon Psychology Services to: