I UNDERSTAND THAT MY TREATMENT WILL NOT BE CONDITIONED ON SIGNING THIS AUTHORIZATION AND THAT I HAVE THE RIGHT TO REFUSE TO SIGN THIS AUTHORIZATION. I UNDERSTAND THAT INFORMATION DISCLOSED AS A RESULT OF THIS AUTHORIZATION MAY BE SUBJECT TO RE-DISCLOSURE BY THE RECIPIENT AND MAY NO LONGER BE PROTECTED BY FEDERAL OR STATE LAW.
I UNDERSTAND THAT PSYCHOLOGICAL AND NEUROSYCHOLOGICAL TEST ORDERED BY A REFERRING PROVIDER WILL BE SENT TO THAT PROVIDER. A REQUEST FOR A COPY OF THAT REPORT MUST BE TO THE REFERRING PROVIDER AND COME FROM THE REFERRING PROVIDER TO THE PATIENT, PARENT OR GUARDIAN.
I UNDERSTAND THAT I HAVE THE RIGHT TO REVOKE THIS AUTHORIZATION BY SENDING A WRITTEN NOTIFICATION. I UNDERSTAND THAT I HAVE THE RIGHT TO INSPECT OR COPY THE PROTECTED HEALTH INFORMATION AS DESCRIBED IN THIS DOCUMENT. I ALSO UNDERSTAND THAT THE EPILEPSY INSTITUTE OF NORTH CAROLINA MAY DENY THE REQUEST.