You may end this authorization (permission to use or disclose information) any time by contacting our office.

If you make a request to end this authorization, it will not include information that may have already been used or disclosed based on your previous permission.

You will not be required to sign this form as a condition of treatment, payment, enrollment, or eligibility for benefits.

You have a right to a copy of this signed authorization.

If you choose not to agree with this request, your benefits or services will not be affected.

I hereby authorize the name(s) or entities written below to release verbally or in writing information regarding any medical, legal court records, educational records, mental health and/or alcohol/drug abuse diagnosis or treatment recommended or rendered to the above identified patient. I authorize these agencies to share information by mail, phone, in person, fax and/or email contact. I understand that these records are protected by Federal and state laws governing the confidentiality of mental health and substance abuse records, and cannot be disclosed without my consent unless otherwise provided in the regulations. I also understand that I may revoke this consent at any time and must do so in writing. A request to revoke this authorization will not affect any actions taken before the provider receives the request.