LOSATS Consent to Disclose/Obtain Information

Please correct the errors described below.

This consent covers treatment period(s):

I understand that my records are protected under the Federal Regulations governing confidentiality 42CFR, Part 2 and/or New York State Mental Hygiene Law and cannot be disclosed without my written consent unless otherwise provided for in the regulations. Further release of information is prohibited by law. I also understand that I may revoke this consent in writing or verbally at any time except to the extent that action has been taken in reliance on it.

Understand that by typing and submitting you understand that it is your intention to provide a legally binding signature for agreement to disclose/obtain information.
Understand that by typing and submitting you understand that it is your intention to provide a legally binding signature for agreement to disclose/obtain information.
Understand that by typing and submitting you understand that it is your intention to provide a legally binding signature for agreement to disclose/obtain information.
(Not to Exceed One Year)

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