All information regarding alcohol and/or Drug abuse or behavioral health will be released unless you restrict by initialing below
Do not release records from alcohol and/or drug abuse or behavioral health information.
I authorize the use and disclosure of my individually identifiable health information as described above, including verbal and written exchanges about the information unless I indicated otherwise. I understand that this authorization is voluntary. I understand that if the person or organization I authorize to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and could be re-disclosed. I understand that my health care and payment for my health care will not be affected if I do not sign this form.
(specify date or event) or, if no date or event is specified, 12 months from the date of signing.
A photocopy or fax of this authorization will be treated in the same manner as the original
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