I understand I have the right to inspect any written information released through this authorization and such an inspection, if requested, will occur in a meeting.
I understand I may revoke this authorization by providing written notice of revocation. I also understand any
information released prior to the revocation may be used for the purpose listed above.
I understand I do not have to sign this authorization. Treatment, payment, enrollment, or eligibility for benefits
cannot be conditioned upon the signing of this authorization.
I understand if the person or organization that receives my information (described above) is not a health care
provider or health insurer the information may no longer be protected by federal or state privacy regulations
(e.g., HIPAA and other privacy regulations).
I understand and agree that a copy of this authorization (including electronic copy, fax, or photocopy) shall
have the same force as the original.
NOTICE TO PERSON/AGENCY RECEIVING MENTAL HEALTH INFORMATION: The mental health information
disclosed herein has been disclosed, and may only be redisclosed, pursuant to the written authorization of the client or the client’s legal representation or as otherwise provided in Chapter 228, Code of Iowa. Any unauthorized redisclosure of mental health information is unlawful and is subject to civil and criminal penalties.