The Protected Health Information is being disclosed for the following purpose: To help identify the client’s needs and strengths, assist in developing treatment
recommendations, assist in screening of eligibility for services and to provide care coordination of substance use disorder services.
This authorization will be in force and effect until: One Year expires.
after Termination of Services. At that time, this authorization to disclose this protected health information
I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the Department of Health.