The information may be shared unless otherwise indicated, orally, in writing, or electronically.
- I have the right to refuse to sign this authorization. Treatment, payment or operations are not conditioned on my authorization.
- I may cancel this authorization at any time by contacting my worker if the release has not already been carried out. (Workers: use form HC12025 to document.)
- A copy of this authorization is as valid as the original.
- I may be required to pay the actual costs of making, certifying and/or compiling the copies of information requested.
- After this information is released, it may be re-released to a third party if allowed by law. However, 42 CFR Part 2 prohibits unauthorized re-release of substance use disorder records.
- If I have questions about the privacy of my records, I may ask my worker for more information.