I understand I have the right to revoke this authorization in writing except to the extent that The Center For Psychology PA has taken action or has relied on the authorization. This Authorization may be revoked by my requesting in writing and delivering a copy of the same to The Center For Psychology, PA.
This authorization will expire 12 months from first date of service.
Once the uses and disclosures have been made, pursuant to this authorization, they may be subject to redisclosure by any recipient and no longer protected.
The Center For Psychology, P.A. will not condition treatment or payment on my providing authorization from this use or disclosure except to the extend provision of health care is solely for the purpose of creating protected health information for disclosure to a third party on provision of an authority for disclosure of the protected health information to such third party.