DATES Covered by this authorization are from: Beginning to End of Treatment.
It is my understanding that this information will be used solely for the purpose described above. I understand that the information which I am authorizing to be released may include psychiatric diagnoses and or drug/alcohol related information.
I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient of your information and no longer protected by the HIPAA Privacy rule.
I understand that I may revoke my permission in writing at any time. Any actions Neural Health Therapies may have taken before receiving notice that the consent has been revoked would not be covered by the revocation. I hereby release Neural Health Therapies and its duly authorized agents from all legal responsibility or liability for the release of information indicated and authorized herein.
I understand that my care provider generally may not condition mental health services upon my signing an authorization unless the mental health services are provided for the purpose of creating health information for a third party.
A fax or photocopy of this form is considered valid.