I understand that this authorization may be revoked by me at anytime (with the exception that Mercyland Psychiatry has already acted in reliance on it) by written notice. I have the right to inspect and receive a copy of the material to be disclosed and receive a copy of the informed consent. This consent will remain in effect until the above request is processed or unless otherwise specified. When health information is disclosed to anyone except a covered facility it would no longer be protected under HIPAA (Health Insurance Portability and Accountability Act of 1996) regulations. Signing this authorization is voluntary and I may refuse to sign. Unless allowed by law, my refusal to sign this authorization will not affect my ability to obtain treatment, receive payment, or eligibility for benefits.
Prohibition of Disclosure: This information has been disclosed to you from records protected by Federal confidentiality rules (42CFR Part 2 and Wisconsin Statute 51.30). 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. I understand I may inspect and receive a copy of the disclosed information.
I understand a photocopy of this consent is as valid as the original. This consent is valid for a period of one (1) year.
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