Please note that children under 18 must be accompanied by a legal guardian. Adults with guardians must obtain written consent from the legal guardian prior to being served. (Please provide a copy of guardianship papers for Adults).
I hereby request and authorize the below-named agency, organization, or individual which possesses information relative to the client named above to release information, as specified, to the agency, organization, or individual named on the request. I understand that the information to be released may include information regarding drug abuse, alcohol abuse, sickle cell anemia, psychological or psychiatric impairments, and/or AIDS (acquired immune deficiency syndrome), AIDSrelated complex (ARC), or HIV antibody testing and/or service planning, treatment, monitoring of progress
This consent shall be valid for ONE YEAR, and not to exceed ONE YEAR or until revoked. This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. The doctrine of informed consent has been explained to me and I understand the contents to be released, the need for the information, and that there are statutes and regulations protecting the confidentiality of authorized information. I further understand that this consent may be revoked at any time except to the extent that action based on this consent has been taken. Revocation must be made directly to the client Record Service serving the facility you are active in. I hereby acknowledge that this consent is truly voluntary and is valid until such request is fulfilled
