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.