I hereby authorize Acclaim Autism, its agents and its employees to release protected health information described above. I confirm I am legally authorized to consent for this patient's healthcare. I understand that my authorization will automatically expire one hundred eighty (180) days after the date of signature on this form.
I understand that I may revoke this authorization at any time. I understand that to revoke this authorization, I must do so in writing to Acclaim Autism, 2929 Arch St, Suite 1700, Philadelphia PA 19104. I understand the revocation will not apply to information that has already been released in response to this authorization.
I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by relevant federal and/or state law. If I have requested to receive health information electronically, I acknowledge and accept the risks described above concerning unencrypted electronic formats. My refusal to sign this authorization will not affect any ability to receive treatment.