Authorization for the Release of Healthcare Information

I hereby authorize NYC Psychology Inc., PC to release the information about my assessment and/or treatment to the following person(s) or facility(ies):

I understand that I refuse to sign this authorization without affecting my eligibility for assessment and/or treatment. I further understand that I may withdraw this authorization at any time by submitting a written request to David H. Rosmarin PhD, 200 West 57th st, Suite 404, New York, NY 10019. Authorization may be withdrawn except to the extent that action has already been taken in reliance on this authorization. I further understand that information released on this authorization is no longer protected by NYC Psychology Inc., PC (e.g, if re-disclosed by recipient). To the extent to which my file contains information regarding alcohol and/or drug treatment (protected by Federal Regulations 42 CFR, Part 2) or HIV antibody/antigen testing (protected by NYS Law), I authorize disclosure of such information.