I retain the right to revoke this authorization in writing prior to the expiration date below.
Treatment may not be conditioned on obtaining the authorization if that is prohibited by the HIPPA Privacy Rule.The information disclosed pursuant to this authorization may be subject to re-disclosure by the designated recipient, and subsequently no longer protected by the HIPAA Privacy Rule. I understand that authorizing the disclosure of the above information is voluntary and I need not sign this form to ensure treatment.
Signature of Client or Client’s Designee