I understand I may revoke this consent at any time except to the extent that action has already been taken in reliance hereon, and if not revoked sooner in writing, this consent will expire 365 days for the date signed. I understand that a copy of release is as good as original for disclosure purposes. I understand that this release or a copy of this released may be mailed/faxed to the appropriate recipients to gain information.

I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. However the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.

I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.

Cheri McCormack Counseling Services, LLC will not condition my treatment, payment, enrollment (if applicable) in a health plan or eligibility for benefits on whether I provide authorization for the requested health disclosure.

I understand that I have the right to refuse to sign this authorization.

Cheri McCormack Counseling Services, LLC

2005 Ironwood Parkway, Suite 210, Cd’A, ID 83814
Phone (208) 661-1495  Fax (208) 545-5222