I UNDERSTAND that enrollment, eligibility, payment, or treatment is not conditioned upon the execution of this authorization. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by those regulations. I understand that fees may be charged for preparing and sending copies of records. I understand that I may revoke this authorization at any time (except to the extent that action has been taken in reliance upon it) by providing written notice of revocation to Dr. Mark Glover.
I UNDERSTAND that my records are protected under Federal Regulations governing confidentiality of alcohol and drug abuse patient records (42 C.F.R. §2.32) and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I specifically authorize the release of confidential information relating to drug and/or alcohol abuse.
I UNDERSTAND that by typing my name below I am authorizing all communication indicated previously for the patient named at the beginning of this form.
If this form has been filled out and signed by someone other than the patient, please fill out the fields below with the responsible party's information.