This authorization, unless revoked earlier, expires on my formal termination from treatment at Ravenwood Health not to exceed 180 days after signing the release, whichever occurs first. I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.
SUD Disclosure Statement:
Statement of Understanding: I (or other individual authorized to sign in lieu) confirm my understanding that, upon my request, I must be provided a list of entities to which information has been disclosed pursuant to the general designation.
I understand and acknowledge that the requested health information may contain information regarding physical and mental illness; HIV testing results or diagnosis; treatment of AIDS/AIDS-related conditions; and/or alcohol or drug abuse, all of which are protected under federal or state confidentiality regulations (42 CRF Part 2, 45 CFR Part 160 and 164, O.R.C. 3701.243, etc.) and these records cannot be re-disclosed without my written consent unless permitted by the regulations. I also understand that my mental health treatment records are protected by HIPAA but that if the recipient of my information is not subject to HIPAA, it may no longer be protected by state or federal law and therefore subject to re-disclosure to a third party
This authorization may be revoked in writing at any time except to the extent the program or person who is making the disclosure has already acted in reliance on it.