SARAH JANE DEVINS, LPC-A1717 WEST AVENUE, AUSTIN, TEXAS 78701512-452-2929 FAX: 512-452-5656AUTHORIZATION TO RELEASE/REQUEST PROTECTED HEALTH INFORMATION
I have read this Authorization and understand what information will be used or disclosed, who may use and disclose the information, and the recipient(s) of that information. I understand that the purpose of releasing this information is for treatment, coordination of treatment, and payment purposes. I also understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned upon me signing this authorization.
I understand that when the information is used or disclosed pursuant to this Authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by state or federal privacy regulations.
I further understand that I retain the right to revoke this Authorization, except to the extent that action has been taken in reliance on this Authorization, if I inform Sarah Jane Devins, LPC-A in writing of my wish to revoke this authorization. Such revocation should be mailed to:
Sarah Jane Devins, LPC-A; 1717 West Avenue, Austin, Texas 78701
This Authorization shall expire when I am no longer receiving psychological and mental health services from Sarah Jane Devins, LPC-A. I fully understand and accept the terms of this authorization.
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