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My signature below signifies that I understand that I am authorizing HEADS to release and receive the below information to and from the person/agency indicated.

I am not giving permission for any re-disclosure of this information other than as specified above.

I request that my consent become invalid in 365 days from the date I sign it.

I understand this authorization is subject to revocation at any time, unless action has already begun in good faith.

I understand that my records are protected under state and federal confidentiality regulations and cannot be disclosed without any written consent unless otherwise provided for in the regulations.

I understand that information held by HEADS is limited to those staff/clinicians whose work assignments reasonably require access to my data within the purpose specified in services provided.

I understand that this consent is valid for one year and that I have the right to rescind this consent at any time.

You have the right to revoke this authorization, in writing, at any time per HIPAA Privacy Policy 164.520, with the exception of those authorizations you signed for routine disclosures for treatment, payment or healthcare operations as permitted by the HIPAA Privacy Rule. HEADS will not condition your treatment, payment, enrollment or eligibility on whether or not you sign this release of information. Be advised that there is potential for your information to be redisclosed by the recipient and no longer protected by 45 CFR, Part 164, Subpart E.