I understand that information regarding my alcohol and/or drug treatment is protected by federal law under the Drug Abuse Prevention, Treatment, and Rehabilitations Act and the privacy provisions of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), and their implementing regulations. See generally 42 C.F.R. Part 2; 45 C.F.R. Parts 160, 164. I understand that my health information, as specified on this form, will be disclosed pursuant to this authorization, that the recipient of the information may redisclose the information and it may no longer be protected by federal law under HIPAA. Federal law governing confidentiality of alcohol and drug abuse patient information noted above, however, will continue to protect the confidentiality of information that identifies me as a patient in an alcohol or other drug program from redisclosure.
I understand that I may revoke this consent verbally or in writing at any time except to the extent that action has been taken in reliance on it, and that this consent will expire in one (1) year unless otherwise specified below.
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment or health care operations if permitted by state law. I will not be denied services if I refuse to consent to disclosure for other purposes.
