Permission to Receive and or Release Confidential Information

Please correct the errors described below.

Understanding that these records may contain information pertaining to substance abuse/use and/or HIV/Hep C, or other communicable disease testing or treatment, the purposes of coordinating treatment, I authorize Just 1 Life Services LLC and Associates to;

To the following agency, organization or person;

The following information, as indicated by my checked boxes;

Just 1 Life Services, LLC is hereby released from any and all legal liability that may arise from the disclosure of the information requested. I certify that this request for disclosures has been made freely and voluntarily. I understand that Just 1 Life Services, LLC will not effectuate my treatment contingent upon my signing this authorization or deny me treatment if I chose not to sign this document.

I understand that I may revoke this authorization at any time in writing, with some exceptions. For more details on when I can and cannot revoke this authorization, I can read the CMHC Notice of Privacy Practices. I understand that if this information is disclosed to a third party, the information may no longer be protected by the federal privacy regulations (HIPPA) and may be re-disclosed by the person or organization that receives the information.

EXPIRES 1 year from today's date.

This information has been disclosed to you from records protected by federal confidentiality rules (42 C.F.R. 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 C.F.R. 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.

Your information will be encrypted.