I hereby consent to the release of any and all records containing Alcohol/Drug Abuse/HIV/Psychiatric diagnoses under the same consideration as above. I understand that such information cannot be released without my specific consent, except under a Court Order. It is my intent that information released is prohibited for any other purpose than that which is stated above.
Note: A patient (18 years or older) must authorize the release of their own information unless patient is incapacitated or deceased. If signing for a minor patient, I hereby state that my parental rights have not been revoked by a court of law. Specific situation(s) may require minor’s authorization.