NOTE: Treatment is not conditioned by having to sign this consent. This information has been disclosed to the above-named recipient from records protected under Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 CFR parts 160 & 164. The information specified above will be disclosed pursuant to this authorization, and the recipient of the information may re-disclose the information, which may no longer be protected by the HIPAA privacy law. This consent is subject to revocation at any time except to the extent that action has been taken in reliance thereon. To revoke this consent, the request must be done in writing to: Support Staff or your therapist at Woodmill Corporate Center, Suite 30, Wilmington, DE 19808. If not previously revoked, this consent expires on date recorded below.
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