I authorize Westside Behavior Therapy to use, disclose, receive, and/or release protected health information (PHI) regarding my child with the following provider/organization.  I understand that this information will be used for the purpose of coordination of care.

I understand that:

1. This authorization is voluntary, and I may refuse to sign it without affecting my child's healthcare.
2. I have the right to request a copy of this form after I sign it as well as inspect or copy any information to be used, disclosed, and/or released under this authorization (if allowed by federal and state law. See 45 CFR § 164.524).
3. I may revoke this authorization at any time by notifying Westside Behavior Therapy in writing.  However, it will not affect any actions taken before the revocation was received or actions taken based on previously shared information.
4. Federal privacy rules for protected health information apply only to health plans, healthcare clearing houses or healthcare providers.  If I authorize disclosure of medical information to other agencies or individuals, the disclosed information may no longer be protected by federal privacy regulations.

I consent to the use, disclosure, receipt, and/or release of the above information.  I understand that the use of this information for any reasons other than the expresses reason stated above is prohibited.  This consent is subject to revocation at any time except to the extant that action has been taken based on information that has already been disclosed.

Unless revoked, this authorization expires 365 days from the date of signature.