I understand that the purpose of this disclosure is for CLIENT TREATMENT COLLABORATION.
I understand that I am giving permission to disclose, release and/or obtain protected health information. Any eligibility for benefits, treatment, payment, or enrollment is not affected by this release of information. Such information may be subject to re-disclosure by the recipient and will thus no longer be protected by the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations and may not be protected by state law.
I further understand that I may decline to sign this form. I also understand that I may revoke this consent to disclose information at any time. If I choose to revoke this consent, I must do so in writing. The authorization will remain in effect for one (1) year.