Release of Information

Re-use of information:

I understand that if I share my protected information with someone who is not legally required to keep it

confidential, that information may be shared with others and may no longer be protected. I also understand

that under no circumstances am I required to release psychotherapy notes.

Right to take back authorization:

I understand that I have the right to take back my authorization at any time. If I terminate this authorization, I will notify my healthcare provider in writing via email or sending a letter to her at:

548 Market Street, #370995, SF, CA 94104-5401

This notice will be in effect when received by my healthcare provider. Any information already shared as a result of this authorization cannot be rescinded.

Expiration:

This authorization will go into effect immediately and remain in effect for one year from the date of my signature unless I specify a termination date.