I do hereby consent Miami Valley Recovery, LLC to disclose my substance use disorder treatment to employees of the pharmacy specified below. Treatment disclosure most often includes, but may not be limited to, discussing my medications with the pharmacist, and faxing/calling in my prescriptions directly to the pharmacy.
Agree to allow pharmacist to contact provider listed above to discuss my treatment if necessary so that my prescriptions can be filled and either delivered to Miami Valley Recovery, LLC or picked-up by employees of the same.
I understand that I may withdraw this consent at any time, either verbally or in writing except to the extent that action has been taken on reliance on it. This consent will last while I am being treated for substance use disorder by the provider specified above unless I withdraw my consent during treatment. This consent will expire 90 days after I complete my treatment, unless the provider specified above is otherwise notified by me.
I understand that the records to be released may contain information pertaining to psychiatric treatment and/or treatment for alcohol and/or drug dependence. These records may also contain confidential information about communicable diseases including HIV (AIDS) or related illness. I understand that these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further disclosures to third parties without the express written consent of the patient.
I acknowledge that I have been notified of my rights pertaining to the confidentiality of my treatment information/records under 42 CFR Part 2, and I further acknowledge that I understand those rights.