By signing this authorization form, I understand and agree that: My protected health information and substance use disorder treatment information is protected under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and federal regulations governing the confidentiality of substance use disorder patient records, 42 CFR Part 2. Recipients of my information pursuant to this authorization may not further disclose my substance use disorder information without my consent, unless permitted under HIPAA; 42 USC § 290dd-242; and 42 CFR Part 2. Recipients will be notified of this obligation in the Prohibition on Re-Disclosure which must accompany all disclosures of my substance use disorder information. 42 CFR § 2.32. I may revoke this authorization in writing at any time by notifying BHWC, except to the extent that BHWC has already used or disclosed information in reliance on my authorization. I will not be denied services if I consent to disclosure, unless disclosure is necessary for BHWC’s proper treatment of me, obtaining payment for my services, or its health care operations.
I have been given time to read, understand, and ask questions about this form.
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