Purpose of Disclosure To release or receive information for the purpose of communicating with Amend Treatment

Treatment Documentation This release is in compliance with Federal regulations (42 CFR Part 2) and with all applicable state and local laws, rules and regulations. Information may not be further disclosed without permission from the client and may not be used to criminally investigate or prosecute any substance use client.

Voluntary Authorization. I understand authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form to assure treatment. I understand I may inspect or obtain copies of the information to be used or disclosed, as provided in 45 CFR 164.524. I understand any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. I understand the information in my health record may include information related to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), behavioral health or mental health services, or treatment for alcohol and drug use.

Revocation. I understand I have a right to revoke this authorization at any time by presenting a written revocation to the Medical Record Department. I understand the revocation will not apply to information already released in response to this authorization. This authorization is valid (if not previously revoked) this consent will terminate upon one year from the date of signature of this form, or the following event/condition:

or the completion of treatment, or at the time of the final insurance billing, as the case may be, whichever is later.