Information released may be verbal, electronic, or written. Released data may include records, treatment notes, and other information.
I understand the information will be used for the Child Medical Evaluation. Nature of records to be released: All medical records including labs and x-rays.
My signature below indicates that I understand what information will be released and the need for the information. I further understand that the information to be released may include information regarding drug and alcohol abuse or AIDS/HIV. In addition, information related to drug and alcohol abuse in my records is protected under federal regulations and cannot be released without my written consent unless otherwise provided in the 42 Code of Federal Regulations Part 2. This consent will expire one year from date of signed consent.
I understand that I may revoke this consent, verbally or in writing, at any time, but that it will remain valid to the extent release based on this consent has already occurred.