I hereby authorize, Innovative Psychological Consultants, 7236 Forestview Lane N., Maple
Grove, MN 55369 (763-416-4167Ph 763-416-4137 Fax) to:
The following organization/person:
My health records from the following dates as listed below:
This authorization will expire on:
I hereby authorize the receipt, disclosure, or exchange of my private health information as specified above. I understand that I may revoke this release at any time by sending written notification to the health care provider. I understand that any release of information made prior to my revocation in compliance with this authorization shall not constitute a breach of my rights to privacy. I understand that if the recipient is not a health care provider or a
health plan, the information disclosed under this authorization may no longer be protected by federal privacy regulations and may be re-disclosed by the recipient.
I understand that my authorization is voluntary and I may refuse to sign it and my refusal will not affect my ability to obtain treatment. I also understand the following consequences may occur by refusing to sign this release: 1) If authorization is to demonstrate to a health plan that a service should be paid for, the health plan may refuse to pay for it; and 2) If the authorization is sought by an insurer because I am seeking enrollment or eligibility, the insurer may deny me the coverage I am seeking.