I hereby authorize Certus Psychiatry & Integrated Care to revoke medical information from the records of:

  • I understand that my information is protected by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), as amended. Regulations governing the Confidentiality of Alcohol and Drug Abuse Patient Records may also apply. I understand that unless revoked, this authorization is valid for the period of time needed to fulfill its purpose and up to three years, except for disclosures for financial transactions, wherein the authorization is valid indefinitely.

    This information is to be revoked to:
  • By signing below, I represent that I have read, understood, and consent to this disclosure.
  • This field is for validation purposes and should be left unchanged.