Right to refuse to sign this authorization: You are under no obligation to sign this form. Except as permitted under applicable law, Pauquette providers may not refuse to provide you treatment or other health care services if you refuse to sign this authorization.

Right to revoke this authorization: You have the right to revoke this authorization, in writing, at any time before it ends. However, revoking this authorization will not affect any disclosures of your health information that were made prior to receiving your written revocation request. Your revocation must be made, in writing, and addressed to: Pauquette Center, Attn: Privacy Officer, 2901 Hunters Trail, Portage, WI 53901.

Right to receive a copy of this authorization: You have the right to receive a copy of this authorization after signing it.

Right to inspect and/or copy: You have the right to inspect and/or receive a copy of the health information that you have authorized to be disclosed by this authorization; however, please know that certain exceptions under federal and state law may apply. To do so you must submit your request, in writing, using the clinic’s “Request for Access to Health Information” form. You may be charged the designated fee for copies of your health records.

Disclosure of patient status: Communications resulting from this authorization will reveal that you receive services at the Pauquette Center for Psychological Services.

Re-disclosure notice to patient: If the organization(s) and/or person(s) authorized by this form to receive your health information are not health care providers or entities or persons who must follow the federal health privacy laws, the health information they receive as a result of your authorization may no longer be protected by the federal health privacy laws, and those organization(s) and/or person(s) may be permitted to re-disclose your health information without your prior permission.

Disclosure notice to recipient of mental health, alcohol and /or drug treatment records: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal Regulations (42 CFR Part 2) prohibit you from making any further disclosure of this information without the specific written consent of the person who is the subject of such information or as otherwise permitted by these regulations. A general authorization or release of medical or other information is not sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.