I understand that Reaching HOPE cannot condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this form or not. If the information authorized to be released pertains to diagnosis and treatment of alcohol and/or drug abuse, I understand the information is protected by Federal Law 42, C. F. R. Part 2. I understand that there is potential for information disclosed, disclosed as a result of this authorization, to be re-disclosed by the recipient and therefore no longer protected by the HIPAA Privacy Regulation. I understand that I may revoke this authorization at any time by giving written notice to Reaching HOPE, or by signing at the bottom of this form, except to the extent that action has already been taken to comply with it. Without such revocation, this authorization will expire at the termination of my treatment at Reaching HOPE unless otherwise requested on this authorization form. I understand that I have a right to refuse to sign this form subject to the conditions noted above. If I sign the form, I am entitled to a copy of that signed form.