By my signature below, I hereby authorize North Star Behavioral Health and its providers to obtain, use and/or disclose my health information for the term of this Authorization.
I understand that once North Star Behavioral Health discloses my health information to the recipient, North Star Behavioral Health cannot guarantee that the recipient will not re-disclose my health information to a third party. Any such third party may not be required to abide by this Authorization or applicable federal or state law governing the use and disclosure of my health information. I understand that I may refuse to sign or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation, or quality of the treatment I receive from North Star Behavioral Health; except, however, if my treatment by North Star Behavioral Health is for the sole purpose of creating health information for the disclosure to the recipient identified in this Authorization, in which case North Star Behavioral Health may refuse to treat me if I do not sign this Authorization. I understand that this Authorization will remain in effect until the term of this Authorization expires or I provide a written notice of revocation to North Star Behavioral Health. The revocation will be effective immediately upon receipt of the written notice by the agent of North Star Behavioral Health except that the revocation will not have any effect on any action taken by North Star Behavioral Health in reliance on this Authorization before receipt of my written notice of revocation.
I have read and understand the terms of this authorization and have had an opportunity to ask questions about obtaining, using, and disclosing my health information. By my signature below, I hereby, knowingly, and voluntarily authorize North Star Behavioral Health to obtain, use and/or disclose my health information in the manner described above.