I give permission to release all my information between Angels Service and this listed on this form. This permission lasts the length of my service enrollment with Angels Service LLC. I understand that information disclosed by this authorization except for Alcohol and Drug Abuse information as defined in 42 SFT Part 1 may be subject to re-disclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act Privacy rule 45 CFR Part 164 and Privacy Act of 1974 5 USC 55sa. I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (GIV). I understand that this is authorization is voluntary.
I also understand that I may revoke this authorization at any time. I further understand that any release of information prior to the rescinded date is legal and binding. I also understand that I may decline to signed this authorization and that my services will no be affected if I do not sign, except that for purposes of determining eligibility for services, eligibility may be denied if authorization is not given.
I further understand that I may a request a copy of this signed authorization and that I may see and copy the information described on this form if I ask for it. I understand that I may request a list of entities to which my information has been disclosed. I understand that unless I specify an expiration that this authorizing is valid so long as I am an active client with Angels Service LLC.