I understand that I may revoke this authorization at any time by notifying Amberleigh Yoegel, LCPC/Director of Compliance & Quality Assurance, in writing, and this authorization will be revoked.
I understand that Aspire Wellness Center, Inc. may not condition treatment, payment, enrollment or eligibility for benefits on my signing this authorization, unless my treatment is related to research and the purpose of this authorization is to enable the protected health information described above to be used for such research.
I understand that information disclosed baded on this authorization may be subject to re-disclosure by the recipient, and no longer protected by Federal privacy regulations. I understand that I may request a copy of this form after I sign it.