Check the following information to be released for the dates of service indicated below.
Dates of service for information selected above to be released: _____________________ to ______________________
(Including psychiatric records related to emotional illness, and information regulated by Federal Public Law 930-282, confidentiality of alcohol and drug abuse clients. Also included are records documenting the diagnosis and/or treatment of AIDS/AC, HIV Positive and other related disease)
This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR, Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client.
I understand that information disclosed by this authorization, except as prohibited by 42 CFR Part 2 or other applicable law, may be subject to re-disclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act Privacy Rule [45 CFR Part 164].
I might be denied services if I refuse to authorize disclosure of information for purposes of assessment, treatment, or payment relating to substance use disorder if refusal is permitted by state law. My refusal to authorize disclosure of information for other purposes will not affect my ability to obtain treatment or services.
If I have authorized disclosure to a generally described group or class of participants in an entity which is not my treatment provider, upon my written request, I must be provided a list of entities to which my information has been disclosed pursuant to that general designation.
I understand that I and/or my parent/guardian/authorized representative, if appropriate, may revoke this authorization at any time, except to the extent that action has been taken in reliance on it, and that the revocation must be signed and dated by me, my parent/guardian/authorized representative. Upon revocation of consent, further release of information shall cease immediately.
Substance use disorder records of Part 2 programs disclosed pursuant to this Consent are protected by federal regulations and cannot be redisclosed without my written consent unless otherwise provided for in the regulations. Any information disclosed pursuant to this Consent other than substance use disorder records or records protected under another state law may be subject to re-disclosure by the recipient.
This authorization will remain in effect until revoked or shall expire on date or event specified below. I understand that I may revoke or cancel this authorization at any time by submitting written revocation in the manner specified by the disclosing entity, except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will expire on the date or completion of the event stated below. If no date or event is specified below, this authorization will expire in one year.