By checking the box (as an electronic signature) and use of this online scheduling and communication tool provided by third-party Calendly (“Scheduling Tool”), I hereby authorize Monte Nido Holdings,LLC (“Monte Nido”) and its respective affiliates, agents, and/or employees, to disclose the information I voluntarily enter into the Scheduling Tool to Calendly for the purposes of facilitating the receipt of information regarding the services available from Monte Nido and/or scheduling an intake assessment appointment.
I understand that authorizing the disclosure of this information is voluntary. I can refuse to sign this authorization. Furthermore, I understand that I may revoke this authorization at any time. If I revoke this authorization, I must do so in writing to the applicable parties named herein.I understand that the revocation will not apply to information which has already been released in response to my prior authorization. Additionally, I understand that treatment or payment cannot be conditioned on my signing this authorization. I understand that any information I disclose through the use of the Scheduling Tool is subject to redisclosure and such information may not be protected by federal or state confidentiality rules such as HIPAA.
This authorization shall expire automatically 10 years from the date of the authorization.
