SPECTRUM BEHAVIORAL HEALTH
New In-take Fax: 845-485-8780
Poughkeepsie Fax: 845-452-7546 / Fishkill Fax: 845-897-3376 / Kingston Fax: 845-331-1479
I hereby give permission to Spectrum Behavioral Health to release/receive information to/from:
My consent is subject to revocation at anytime (except to the extent that action has been taken in reliance on my consent) and expires in 1 year unless an earlier date is specified.
For persons receiving treatment for alcohol or drug abuse, any information disclosed as per this release is protected by Federal Law. Federal Regulations (42 CFR Part 2) prohibit any re-release or further disclosure of information without the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose.