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I understand that such disclosure will be made for the purpose of evaluation and/ or continued treatment. If other, please specify:

I understand these records include drug/ alcohol/ mental health/ communicable disease related information I understand that information release could contain reference to or results of HIV antibody testing.
I understand that this information is confidential and protected by federal law. I understand that the potential exists for health information that is release with my authorization to be re-disclosed by the recipient. and to be no longer protected by the Federal HIPAA law.
A photocopy of this authorization should be considered as a valid as the original. I understand that this consent is subject to revocation by the undersigned at any time except to the extent that action had been taken in reliance hereon and in any event. shall expire one (1) year from the date of signature.

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