I understand the following:

» I authorize the use and disclosure of my individual identifiable health information as described above, including verbal and written exchanges about the information unless I indicated otherwise.

» I understand authorization is voluntary and I may refuse to sign it. Unless allowed by law, my refusal to sign will not affect my ability to obtain treatment, receive payment or my eligibility for benefits.

» Once the records are released, the clinic or hospital releasing my records cannot prevent them from being released to a third party. At that point, the records may no longer be protected by state and federal privacy laws.

» I understand that I may revoke this consent at any time by notifying the providing organization in writing, except to the extent that action has already been taken in reliance on it and that in any event this consent expires automatically as described above. I also understand the Chemical Dependency client’s/patient’s records are protected by the Federal Law (42CFR Part 2) and cannot be disclosed without this written consent unless otherwise provided in the federal regulations.