If Dr. Gould or his midlevel providers is requesting this authorization from you for our own use and disclosure or to allow another health care provider or health plan to disclose information to us:
- We cannot condition our provision of services or treatment to you on the receipt of this signed authorization;
- You may inspect a copy of the protected health information to be used or disclosed; and
- You may refuse to sign this authorization
You have the right to revoke this Authorization at any time, provided that you do so in writing and except to the extent that we have already used or disclosed the information in reliance on this authorization.
Unless revoked earlier or otherwise indicated, this Authorization will expire in 365 days from the date of signing or shall remain in effect for the period reasonably needed to complete the request.
The information released has a potential for information to be re‐disclosed by the person or organization to which it is sent. The privacy of this information may not be protected under the Federal Privacy Rule depending on whom the information is disclosed to.