This will document authorizes your provider(s) to release and receive written and/or verbal information regarding your treatment while with Insight Wellness. By signing this document you understand that your therapists and/or representatives of Insight Wellness will communicate with listed provider(s) on your behalf.
(If you have more than one provider please complete a form for each - including your PCP or Pediatrician)
By signing you understand that your expressed consent is required to release any health care information relating to testing, diagnosis, and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health or drug/alcohol treatment or use.
You have a right to inspect and to receive a copy of the information to be disclosed and you may revoke this authorization at any time in writing, except to the extent that action has to be taken based on this authorization. You understand that you may specify a date for the expiration of this authorization, but that it shall expire by Law, without my express revocation, one year from the date written below, unless the Client is a resident of a nursing home.
Any released information may be beyond the reach of protection of federal law (HIPAA).