Authorization: I certify that this request has been made freely, voluntarily, and without coercion and that the information given is accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this authorization, in writing, at any time except to the extent that action has already been taken to comply with it. Written recovation is effective upon receipt of the Release of Information Unit at the facility housing the records. Re-disclosure of my medical records by those receiving the above-authorized information may be accomplished without my further written authorization and may no longer be protected. Without my expressed revocation, the authorization will automatically expire: (1) upon satisfaction of the need for disclosure; (2) on (date supplied by client); (3) under the following conditions:
I understand that tmy records are protected under the federal regulations governing confidentiality of Alcohol and Drug Abuse Client Records, 42 CFR part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. For court ordered clients, this information may be re-disclosed for open court per conversation between the treatment provider, judge, and attorneys. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows: