This Authorization is valid until you are discharged from this incident of care or until retracted in writing.
You have the right to revoke this Authorization, in writing, at any time by sending such written notification to 910 S. Chapel St., Ste. 102, Newark, DE 19713, OR by completing a Notice & Revocation of Consent online at www.midatlanticbh.com. However, your revocation will not be efective to the extend that Mid-Atlantic Behavioral Health, LLC has taken action in reliance on this Authorization or if this Authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
I understand that Mid-Atlantic Behavioral Health, LLC generally may not condition behavioral health services upon my signing an authorization unless the psychological services are (i) research-related; or (ii) provided to me for the purpose of creating health information for disclosure to a third party.
I understand that information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient of my information and no longer protected by federal privacy regulations. However, any disclosure of information that pertains to the treatment or diagnosis of durg or alcohol abuse or permitted hereunder shall be acoompanied by the following written statement:
"This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general Authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient."
Any fascimile, copy, or photocopy of this Authorization shall have the same effect as the original.