Release of Information Form

I understand that my records are protected under the Federal Confidentiality Regulation (42 CFR Part 2) and cannot be released or re-released without my written consent unless otherwise provided for in the regulation. I understand that these records may include information regarding treatment and related services for alcohol and/or substance abuse, communicable disease documentation, human immunodeficiency virus (HIV) or for mental health treatment or counseling. I also understand that I may revoke this consent at any time, except to the extent that release has already occurred.

This consent is valid for 12 months from the date signed by the patient or authorized party below, unless revoked by me prior to that date, upon the completion or satisfaction of the event or conditions specified; whichever comes first. A copy of this authorization shall be valid as the original.

I understand that the following fees may apply:

— Record Retrieval $25.00
— Charge $.25 (per page over 10 pages)
— 1-2 Day Service $10.00