Consent for Release of Medical Information

I specifically authorize Psychiatry of Austin or AutoPsych to disclose my Protected Health Information as  described on this form to the recipients listed above. I understand that when the information is used or disclosed pursuant to this authorization, it may be subject to re disclosure by the recipient and may no longer be protected by state or federal privacy regulations. I further understand that I retain the right to revoke this authorization, if done according to the steps set forth above.  I understand Psychiatry of Austin or AutoPsych is authorized by me to use or disclose my Protected  Health Information for a purpose (described in this document) other than treatment,  payment, or healthcare operations. I have read the authorization and understand what  information will be used or disclosed, who may use and disclose this information, and the  recipient(s) of that information. I understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned upon my signing this authorization.  Psychiatry of Austin or AutoPsych reserves the right to disclose information electronically for treatment, payment, or healthcare operations, unless otherwise required by law.