Common use of Authorization to Disclose Information Clause in Contracts

Authorization to Disclose Information. To Primary Care Physician If you are an insurance client, you must fill out this form. If you do not want your records released to your Primary Care Physician, check the third option below, sign and print your name. I understand that my records are protected under the applicable state law governing health care information that relates to mental health services and under the federal regulations governing Confidentiality of Alcohol and Drug Abuse patient Records 42 CRF Part 2, and cannot be disclosed without my written consent unless otherwise provided for in state or federal regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it. This release will automatically expire twelve months from the date signed. I, hereby authorize