The client, or the client’s representative, must read the following statements:
1. I understand that this authorization will expire on ___90 days or ___one (1) year from the date of this signature.
2. I understand that I may revoke this authorization as described in the Notice of Privacy Practices at any time by notifying Mind Spa LLC in writing, but if I do, it will not have any effect on any actions they took in reliance on my authorization before they received the revocation.
3. I understand that any drug and alcohol abuse records are confidential and will not be released without my express written consent unless the situations discussed in the “Notice of Confidentiality of Alcohol and Drug Abuse Patient Records,” which I have received, occur.
4. Records requested may be protected under federal regulations (42 C.F.R., Part 2, and HIPAA), and state confidentiality laws and regulations and cannot be released without my consent unless otherwise provided for by these regulations and laws.
5. If you refuse to sign this authorization to release or obtain your records, the refusal will have no effect on you receiving services.
FURTHER, THE PHI AUTHORIZED FOR RELEASE MAY INCLUDE RECORDS WHICH MAY INDICATE THE PRESENCE OF A COMMUNICABLE OR NONCOMMUNICABLE DISEASE. I FURTHER UNDERSTAND THAT MY PHI MAY INDICATE THAT I HAVE BEEN TREATED FOR PSYCHOLOGICAL OR PSYCHIATRIC CONDITIONS.
This form applies to all emancipated minors, and must be signed by that minor rather than the parent or legal guardian.