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I understand that this agency cannot guarantee that the Recipient will not redisclose my health information to a third party. The Recipient may not be subject to federal laws governing privacy of health information. However, if the disclosure consists of treatment information about a consumer in a federally-assisted alcohol or drug abuse program, the Recipient is prohibited under federal law from making any further disclosure of such information unless further disclosure is expressly permitted by written consent of the consumer or as otherwise permitted under federal law governing Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR, Part 2).
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I understand that, except when I am (1) receiving research-related treatment or (2) receiving health care solely for the purpose of creating information for disclosure to a third party, I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain treatment from this agency.
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I understand that I may revoke this Authorization in writing at any time, except that the revocation will not have any effect on any action taken by this agency in reliance on this Authorization before written notice of revocation is received by this agency. I further understand that I must provide any notice of revocation in writing to the Privacy Officer at this agency.
I have read and understand the terms of this Authorization and its use for disclosure of my health information.
SIGNATURE:
Signature below must be provided by either:
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The individual served whom is 18 years of age or older whom doesn't have a legal guardian, OR
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The legal guardian if the individual is a minor under the age of 18 or is an individual whom has been assigned a guardian by legal authority.