Health information may be disclosed(as follows):
Any and all health information other than psychotherapy notes may be released, including, but not limited to, mental health records protected by the Lanterman-Petris-Short Act, drug and/or alcohol abuse records, if any, except as specifically provided below.
I understand that I may revoke this authorization at any time by notifying the Center for Fetal Medicine and Women’s Ultrasound inwriting. My revocation will not affect actions taken by the medical practice prior to its receipt. I understand that, under California Law, that all recipients of health care information are prohibited from re-disclosing it except as required or permitted by law. I am signing this authorization voluntarily and treatment, payment, or my eligibility for benefits will not be affected. A copy of my identification is attached. If completed by a personal representative, legal documentation of sch is attached.
