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I request and authorize Upper Valley Behavioral Health Corp. to release healthcare information of the patient named above to:
I understand the following:I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.I understand that if the person or entity that receives the described records/information is not subject to federal privacy regulations or other laws, the records/information may be re-disclosed and no longer protected by those regulations. I understand that the healthcare provider may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization. I may refuse to sign this authorization
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Exp Date (One year from date of request): 03/30/2024
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We do not accept Medicaid or Medicare.
We do not accept self-pay patients.
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