This authorization allows TelepsychHealth to use and disclose (release) certain PHI, which includes medical records, as I have directed.
I understand that:
• The PHI may include information about mental health, psychotherapy notes, substance and/or alcohol abuse, HIV/AIDS, and STDs.
• This authorization may be used to share the same type of PHI indicated above which may be created in the future, until the expiration date.
• This authorization will remain in effect for one (1) year or until I revoke it in writing (i.e., tell TelepsychHealth to cancel it).
• I have the right to revoke this authorization at any time, if I do so in writing to the organization named above and that the revocation will not apply to action already taken as a result of this authorization.
• I may refuse to sign this authorization and doing so will not affect my treatment, payment, enrollment, or eligibility for benefits or the quality of care that I will receive.
• I understand that PHI released per this authorization may no longer be protected by state law or the federal health privacy law and could be re-disclosed by the person or entity that receives it.