I First Name Last Name Consent for the release and authorization the disclosure and use of my protected health information by Journey Healthcare, in accordance with federal and/or state law, whichever is more protective of the client's confidentiality, by written copies, facsimile or verbal communication to:
I also understand:
I understand that I may revoke all or part of this authorization verbally or in writing.Please contact the office if you wish to revoke this consent.
This Consent/Authorization complies with the Privacy Regulations contained within Federal Register Vol. 65, Part II, Part 164; SubPart E 164.508.
PROHIBITION OF REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal regulations prohibit you from making any further disclosures of this information except with the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. A general release of medical or other information is NOT sufficient for this purpose.