I understand that the confidentiality of the information is protected by Federal Law 42.C.F.R. Part 2.
I understand that there is potential for information disclosed, as a result of this release to be disclosed by the recipient and therefore no longer protected by the HIPAA Privacy Regulation.
I understand that I may revoke this release at any time by giving written notice to 3:16 Parenting, PC., except to the extent that action has already been taken to comply with it. Without such revocation, this release/authorization will expire one year from the date of my signature.
I understand that I have a right to refuse to sign this form subject to the conditions noted above or if I sign I am entitled to a copy of the signed form.