I understand that I may revoke this release at any time, otherwise this release will automatically expire one year from the date of signature. I also understand that I may revoke this authorization before it expires by providing a written revocation. I further understand that I have the right to inspect disclosed information under appropriate conditions established by my provider (psychologist,therapist). I understand that authorizing the disclosure of this information is voluntary. I can refuse to sign this authorization. I need not sign this form to assure treatment. I understand that if the person(s) or organization authorized to receive this information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations. However, there may be other federal or state laws that require the information to remain confidential.
I understand that my psychologist cannot guarantee the confidentiality of documents transmitted over fax or email.