I may cancel this authorization in writing as allowed by law. This would not affect any actions already
taken based upon my original request. There are two ways to cancel this authorization:
- Sign and date a revocation form. This form is available from WCPA; or
- Write, sign and date a letter to WCPA to cancel the authorization.
I understand that once WCPA gives out information, WCPA has no control over it. The recipient might
re-disclose it. Privacy laws may no longer protect it.
I understand that I am agreeing to the exchange of health care information regarding receiving testing
and/or treatment for psychiatric disorders, mental health, behavior, and/or drug and/or alcohol use.