Please read the terms of this authorization before signing.
Expiration
Unless sooner revoked this authorization expires ONE YEAR FROM THE DATE OF SIGNATURE.
Revocation, Disclosure
I understand that I have a right to revoke this authorization, in writing at any time, by sending written notification to LBCH at address above. I fully understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization. FORM OF DISCLOSURE. Unless you have specifically requested in writing that the disclosure made in a certain format, we reserve the right to, disclose information in any manner we deemed to be appropriate with applicable law included but not limited to verbally, in paper format or electronically. RE-DISCLOSURE. The potential for information disclosed pursuant to the authorization is potentially subject to re-disclosure and is no longer protected by Federal code. Federal Law prohibits the person or organization to which disclosure is made from making any further disclosure of substance abuse treatment information unless further disclosure is expressly permitted by written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R. art 2. Other types of information may be re-disclosed by client if the information involves the following circumstances: Medical or life threatening emergency.
Conditions of Eligibility
I fully understand that my treatment, payment, enrollment or eligibility for benefits is not contingent upon whether I give authorization for the request for disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences: If services are hindered, clinicians are prevented from properly advocating or acting in the client's best interest, or danger is created due to client's refusal to sign authorization then LBHC may choose not to continue services to client.
Signatures
If signing as a personal representative of an individual, describe your authority to act for this individual (power of attorney, healthcare surrogate, etc.). I will be given a copy of this authorization for my records.