I understand I may revoke this authorization by written request at any time to the address listed at the top of this form.
I understand that the revocation will not apply to the information that has already been released in response to this authorization.
This authorization will automatically expire one year from the date of my signature, or a lesser period of time if specified here. The expiration period noted here may exceed one year only in certain situations as specified by law.
I understand that once the information is released pursuant to this authorization, Plymouth Psych Group cannot prevent the re-disclosure of the information to another third party.
I understand this authorization must be filled out completely and signed in order to be considered valid.
A copy of this authorization is as valid as the original bearing my signature.
I understand there may be a charge associated with the Release of Information Services rendered. There is no charge for release of information to other health care facilities.