I understand that my records are protected under Federal Regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke the consent at any time except to the extent that action has been take in reliance on it (e.g. probation, parole, etc, and that in any event this authorization expires one year from today's date or
NOTICE TO PERSONS RECEIVING THE ABOVE INFORMATION:
The above information cannot be disclosed to other agencies or persons. Federal Regulations state: "This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal Regulations (2CFR Part 2, June 1987 prohibit you from making any further discloser without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general
authorization for release of medical information is NOT sufficient for this information.