I understand that this health information may inclde HIV-related information and/or information relating to the diagnosis or treatment of psychiatrict disabilities and/or substance abude and that by signing this form, I am specifically authorzing information relating to:
Substance abuse (inc: alcohol/Drug abuse), Mental Health, Psychotherapy Notes, and/or HIV related information (ins:aids related testing).
The confidentiality of this record is required under the ariz. rev. stat § 36-661, ariz. rev. stat § 36-664, ariz. rev. stat § 20-448.01©, ariz. rev. stat § 20-448-
01€, ariz. rev. stat § 36-507 & ariz. rev. stat § 36-509. All of these statutes can be found on the Arizona Legislator government website. This material shall
not be transmitted to anyone without written consent or authorization as provided in these statutes. By signing I understand I am authorizing the release
of the above stated records, separate from my general healthcare information.