I release the above entity that disclosed this information from any legal responsibility or liability for disclosure of the above information to the extent that the information was used for its stated purposes. Information used by or disclosed to other organizations pursuant to this authorization may no longer be protected by our Privacy Rule, but further disclosure by organizations other than. requires my additional signed release.
I understand that my records are protected under federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be Disclosed without my written consent unless otherwise provided for in the regulation. I understand that I may revoke this consent verbally or in writing at any time except to the extent that the action has been taken in reliance on it. This authorization expires two years from the date of the patient's signature unless otherwise stated.
Unless I have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including but not limited to written or electronic format.
Federal law prohibits the person or organization to whom disclosure is made from making any further disclosure of this information without written authorization from the person to whom it pertains or as otherwise permitted by 42 CFR Part 2.