I, the undersigned, have read the above and authorize the staff of the disclosing/releasing facility named to disclose/release such information as herein contained. I understand that this consent may be withdrawn by me at any time except to the extent that action has been taken in reliance upon it. This consent shall expire 12 months from its signing, unless a different time period, event or condition is specified below, in which case such time period, event or condition shall apply. I also understand that any disclosure/release is bound by Title 42 of the Code of Federal Regulations governing the confidentiality of alcohol and drug abuse patient records, as well as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 45 CFR Parts 160 & 164; and that redisclosure of this information to a party other than the one designated above is forbidden without additional written authorization on my part. NOTE: When applicable, any information released through this form will be accompanied by "Form A-4400-Prohibition on Redisclosure of Information Concerning Alcoholism Patient" (TR-1[A-4400]).
I understand that generally Choices Mental Health Counseling PLLC may not condition my treatment on whether I sign a consent form, but that in certain limited circumstances I may be denied treatment if I do not sign a consent form. I have received a copy of this form, as recognized by my signature below.