• Authorization For Use and Disclosure of Substance Use Disorder Information

  • Client Information

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  • I authorize the use and disclosure of my health information as described above. I understand that if I do not sign for disclosure within Northwestern Mental Health Center and/or between other Substance Use Disorder providers and Northwestern Mental Health Center regarding continuity of care, Northwestern Mental Health Center may choose not to initiate treatment or may limit treatment options.

    I understand that I may revoke this authorization in writing at any time, except to the extent action has already been taken in reliance on it. I understand that his authorization will expire 12 months from the date of signing this authorization.

    A photocopy or fax of this authorization will be treated in the same manner as the original.

  • My signature indicates that I am legally authorized to sign on behalf of the client.

  • My signature indicates that I am legally authorized to sign.

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