This authorization shall remain in effect throughout the period of involvement with clinical psychology.
You have the right to revoke this authorization, in writing, at any time by sending such written notification to our office address.
However, your revocation will not be effective to the extent that we have taken action in reliance on the authorization.
I understand that NeuroBridge LLC generally may not condition services upon my signing an authorization unless the services are provided to me for the purpose of creating health information for a third party.
I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the information recipient and no longer protected by the HIPPA Privacy Rule. I understand all of the aforementioned, and with informed consent and of my own free will, authorize this disclosure of protected health information.