I further understand that [Audrey Oxenhorn MSW, LCSW- Love Makes a Family LLC] will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences:
Form of Disclosure
Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.
I understand that there is the potential that the protected health information that is disclosed pursuant to this the authorization may be re-disclosed by the recipient and the protected health information will no longer be protected by the HIPAA privacy regulations unless a State law applies that is more strict than HIPAA and provides additional privacy protections.
I will be given a copy of this authorization for my records.