I understand and acknowledge that the requested information may contain information regarding physical and mental illness, HIV test results
or diagnosis, AIDS or AIDS related conditions, alcohol and/or drug dependence/abuse*. I also understand that information used or disclosed
according to this authorization may be subject to re-disclosure by the recipient and may no longer be protected.
I understand that I may see and copy the information described on this form if requested in writing. I also understand that the provider may not
condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization. The health care providers listed above
will not receive financial or in-kind compensation in exchange for using or disclosing my health care information.
I understand I have a right to revoke this authorization (in writing) at any time. I understand that the revocation will not apply to information that
has already been released in response to this authorization. If not revoked, this authorization will expire one year from the date written below or on the following date, event or condition (if earlier):
*Prohibition Against Re-Disclosure: 42 CFR part 2 prohibits unauthorized disclosure of these records. This record which has been disclosed to you
is protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of this record unless
further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed in this record or, is otherwise
permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose (see § 2.31).
The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder,
except as provided at §§ 2.12(c)(5) and 2.65. **If other than client’s signature, a copy of legal paperwork verifying the client’s personal representative
MUST accompany the request unless otherwise on file with provider (e.g., court appointed guardian, durable power of attorney for healthcare,
grandparent power of attorney). Exception: Parent signing for client under the age of eighteen and the County agency holding custody.