I understand that I have the right to revoke this authorization, in writing, at any time by sending notice to Kentucky Mental Health Care, LLC. I understand that a revocation is not valid to the extent that Kentucky Mental Health Care, LLC has acted in reliance on such authorization. This authorization does not expire until I submit a written request. A copy of this release shall have the same force and effect as the original.
NOTICE TO RECEIVING PROVIDEROR ORGANIZATION: You may not re-disclose any of this information unless the person who consented to this disclosure specifically consents to such re-disclosure. I understand that there is a potential for disclosure of this information by the recipient and, if that occurs, federal law may not protect the information.