I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to:
Phoenix Mental Health and Wellness, PLLC
5551 South White Mountain Road Unit 2
Show Low, AZ 85901
I understand that: In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data. I understand that I do not need to give any further permission for the information detailed above to be shared with the person(s) or organization(s) listed above. I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or to pay for the services I receive.
There is potential for information disclosed in to the authorization to be subject to HIPAA redisclosure by the recipient and no longer be protected by the Privacy Rule.