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.