Terms of Release of Information - READ CAREFULLY

By signing a Release of Information, you are agreeing to these important terms:

(1) I allow my insurance company or group health plan to re-disclose my information as necessary for payment, for their internal business purposes, or if my insurance company or group health plan is required to make the disclosure by law.

(2) 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 regulations. I understand that this disclosure will reveal my presence as a patient at this treatment facility or that I am receiving this type of treatment.

(3) I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it by contacting Recovery Help in writing. This consent will last for 180 days after I leave treatment, or, in the case of payment, when my account has been settled, unless the program and/or physician specified above is notified by me that I am revoking my consent.