1. I understand that, unless withdrawn, this authorization will not expire unless requested otherwise. A photocopy of this form will be considered as valid as the original.
2. I understand that I may revoke this authorization at any time by notifying Devine Counseling Services LLC, in writing, and this authorization will cease to be effective on the date notified.
3. I understand that information used or disclosed pursuant to this authorization may be subject to re- disclosure by the recipient and no longer be protected by Federal privacy regulations. However, other state or federal law may prohibit the recipient from disclosing specially protected information, such as substance abuse treatment information and mental health information.
4. I understand that my refusal to sign this Authorization will not jeopardize my right to obtain present or future treatment for psychiatric disabilities except where disclosure of the information is necessary for the treatment.
By signing below, I acknowledge that I have read and understand this authorization.
