Consent to Disclosure of Information

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‍AUTHORIZATION OF SALMA HEALTH TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

I authorize Center for Neurohealth, Inc., d/b/a Salma Health (“Salma Health”) to use or disclose my health information (including any records Salma Health has or may obtain related to your mental health, any developmental disabilities, substance use disorder treatment, HIV/AIDS testing, genetic testing or counseling, and reproductive health) with the recipients I have selected during the term of this Authorization.  I understand that once Salma Health discloses my health information to the recipient, Salma Health cannot guarantee that the recipient will not re-disclose my health information to a third party.  Further, the recipient may not be required to abide by this Authorization or applicable federal law governing the use and disclosure of my health information.  However, if my information includes alcohol or drug abuse treatment program records or information, the confidentiality of the records or information is protected by federal law (42 C.F.R. Part 2) that prohibits re-disclosure except with my specific written consent.

I understand that I may refuse to consent to or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of my treatment at Salma Health; except, however, if my treatment at Salma Health is for the sole purpose of creating health information for disclosure to the recipient identified in this Authorization, Salma Health may refuse to treat me if I do not sign this Authorization.  

I understand that, if I do not specify a date on which this Authorization will expire, it will expire in 12 months. I understand that this Authorization will remain in effect until the term of this Authorization expires or I provide a written notice of revocation to Salma Health’s Privacy Office at the address listed below.  The revocation will be effective immediately upon Salma Health’s receipt of my written notice, except that the revocation will not have any effect on any action taken by Salma Health in reliance on this Authorization before it received my written notice of revocation.

I may contact Salma Health’s Privacy Office by email at privacy@salmahealth.com.

I have read and understand the terms of this Authorization.  By agreeing to this Authorization, I hereby, knowingly and voluntarily, authorize Salma Health to use or disclose my health information in the manner described above.