I understand that I may revoke this authorization in writing, which will take effect on the date it is received, except to the extent that Insyte Psychiatric has already taken action in reliance upon my authorization, or as a condition of obtaining insurance coverage or required by applicable laws or regulations as set forth by InsytePsychiatric’s Notice of Privacy Practices.
I understand that if the above named person or entity is not a heath care provider or part of a health plan covered by federal privacy regulations and this form authorizes the release of my health information, my health information may be re-disclosed by the person or entity I have named above and will no longer be protected by these regulations. However, the person or entity above may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.
I understand that if I refuse to sign this form, Insyte Psychiatric will not disclose my information to the person or entity named above, unless otherwise required by law. Furthermore, I understand that Insyte Psychiatric will not condition any treatment or services on my signing this form.