Specific Information to Be Released:
Physical Health/Medical Summary, Immunization records
Purpose of Release:
To aid in treatment planning.
I understand that this authorization is subject to revocation by me (us) at any time except to the extent that action has been taken in reliance thereof. I also understand that this authorization will expire sixty (60) days from the date signed unless otherwise specified.
Prohibition on Redisclosure: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. FEDERAL REGULATIONS (42 CFR PART 2) prohibit you from making any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by 42CFR PART 2. The general authorization for release of medical or other information is NOT sufficient for this purpose. The FEDERAL RULES restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client. The undersigned hereby authorizes and gives this consent voluntarily. I understand that I have a right to inspect the information being released as permitted under the Privacy Rules. I also understand that the provision of services is not contingent on my decision concerning this release of information, unless I am receiving treatment /services solely for the purpose of creating information for disclosure to a third party or if I am receiving research related treatment. I understand that the Provider cannot guarantee that the Recipient will not disclose my health information to a third party. The Recipient may not be subject to federal laws governing privacy of health information.