By checking this box I hereby understand that I'm giving my signature as consent for Renewed Spirit Biblical Counseling to disclose/discuss the submitted information. I understand that Tambra Molloy at Renewed Spirit are in no way legally responsible for the information I have submitted. By checking this box I hereby understand that I'm giving my signature as consent for Renewed Spirit Biblical Counseling to disclose/discuss the submitted information. I understand that Tambra Molloy at Renewed Spirit are in no way legally responsible for the information I have submitted. By checking this box I understand that I may only revoke this form by notifying, in writing, the person, department or office authorized by this form to release information. I further understand that, after this date, I will need to sign a new release form should I wish to continue to authorize the release of information. By checking this box I understand that this consent is valid until one year from the date of the signature, unless I specify an alternative expiration date or condition. This form provides and indefinite disclosure for information released in regard to financial transactions. I also understand that I may revoke this authorization at any time. I further understand that any action taken on this authorization prior to the rescinded date is legal and binding. I understand that my information may not be protected from re-disclosure by the requester of the information; however, if this information is protect by the Federal Substance Abuse Confidentiality Regulations, the recipient may not re-disclose such information with my further written authorization unless otherwise provided for by state or federal law. I understand that if my record contains information relating to HIV infection, AIDS or AIDS-related conditions, alcohol abuse, drug abuse, psychological or psychiatric conditions, or genetic testing this disclosure will include that information. I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment for services, or my eligibility for benefits. However, if a service is requested by a non-treatment provider (e.g., insurance company) for the sole purpose of creating health information (e.g., physical exam), service may be denied if authorization is not given. If treatment is research-related, treatment may be denied if authorization is not given. I further understand that I may request a copy of this signed authorization.
