Information Authorization
AUTHORIZATION TO USE AND/OR DISCLOSE HEALTH INFORMATION
I authorize Christian Management Services to use or disclose my health information as described below.
| Type of Information Disclosed | Recipient of Information | Purpose of Disclosure |
| PHI from intake form | Therapists in our association | Therapist’s intake process |
| PHI from intake form | Business Operations | |
| PHI from intake form | MailChimp | Communication |
| PHI from intake form | Cognito Forms | Business Operations |
| PHI from intake form | Other Business Associates | Business Operations |
I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the HIPAA Privacy Rule may no longer protect the information.
I understand that Christian Management Services may receive compensation related to the use or disclosure of the requested information.
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Benjamin Deu at 13101 Washington Boulevard, Suite 215, Los Angeles, CA 90066. I understand that the revocation will not apply to information that has already been released in response to this authorization.
This authorization will expire upon my written revocation of authorization.
I understand that if I do not wish to authorize the use and disclosure of my protected health information as described in this authorization and in the Notice of Privacy Practices that I may go directly to the therapist and complete my intake in person.