I hereby authorize the use and/or disclosure of my protected health information (PHI) as described below. I understand that:
This authorization allows for the release and/or exchange of confidential information between my therapist and the individual or organization named on this form.
The purpose of this disclosure is solely limited to the reasons I have selected on this form (checkboxes).
I understand that I may refuse to sign this authorization, and my refusal will not affect my ability to receive treatment, payment, or eligibility for benefits.
I have the right to revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance upon it.
I understand that once information is disclosed per this authorization, it may no longer be protected by HIPAA if it is shared with someone not legally required to maintain its confidentiality.
This authorization is valid for one year from the date it is signed unless I indicate an earlier expiration date or revoke it in writing sooner.
By signing this form digitally, I certify that I am voluntarily providing my informed consent and understand the implications of this release.