AUTHORIZATION TO SUBMIT REPRESENTATION OF CARE
Client Name __________________
Date of Birth __________________
I, ________________________, hereby authorize _____________________ to post an anonymous review on EDTXReviews.org regarding his/her perception of my treatment experience(s) at _____________________________ (treatment center(s).
This authorization shall remain in effect until (give date or event): (until revoked)_____, (6 months) _____, (1 year) _____, other____________
______________________________
Client Name:
___________________________________________________
Address:
___________________________________
Signature of Client:
__________
Date:
___________________________________
Signature of Parent, Legal Guardian or Authorized Representative of Client.
__________________________________
Relationship to Client:
____________
Date:
You have the right to revoke this authorization, in writing, at any time by sending such written notification to my office address. However, your revocation will not be effective to the extent that I have taken action in reliance on the authorization. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by EDTXReviews.org for research purposes and that the information provided may not be protected by the HIPAA Privacy Rule.