I understand that the sharing of information may assist in providing high quality services by: improving assessment and treatment planning, sharing information relevant to treatment, and when appropriate, coordinating treatment services.
I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to OMNI Youth Services, Attn: Doryce McCarthy. I further understand that revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization prior to revocation.
Unless revoked sooner, this consent becomes effective upon the date signed and expires no later than six months from the below date: