I understand that my records are protected under Federal regulations governing Confidentiality of Alcohol and Drug Abuse Initials Patients Records, 42 C.F.R. Part 2, and the health insurance portablility and accountability act of 1996("HIPPA") 45 C.F.R. pts 160 & 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent action has been taken in reliance on it, and that in any event, this consent expires automatically one year from today. I hereby authorize and request Fifth Street Counseling IV, Inc. to release, receive or exchange information with the above named person(s) or agency.