1) I understand that my records may contain documentation of psychiatric conditions, medical history and substance use, and that this information will be released as part of my record. 2) I understand that if the person or entity receiving this information is not covered by federal privacy regulations, this information will no longer be protected and may be redisclosed. 3) I understand that I may revoke this authorization at any time, but revocation will not apply to information that has already been released. 4) I understand that a copy, email or FAX of this document is just as valid as the original document. A photocopy of this authorization is as valid as the original form and I have a right to receive a copy upon request. 5) I understand that my records are protected under the Federal regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations.
Ipermit the following disclosure of information about me to be made in the format requested, including by telephone, fax or mail:
1. I permit: Any physician or other medical/care provider, hospital, clinic, therapist and other medical related facility or service, pharmacy benefit administrator, insurer, employer, government agency, group policyholder, contract holder or benefit plan administrator to disclose to Windsong Family and Psychiatric Associates information about my health.
2. I permit: Windsong Family and Psychiatric Associates the right to contact my healthcare provider on my behalf to obtain clarifying information (subjective to all state laws) for any
I understand that the information that is collected and discussed is to be treated with
confidentiality. However, directly relevant information may be shared with appropriate parties that is deemed necessary.