I understand that I may revoke this authorization at any time with written notification, but that the revocation will not have any effect on the information released prior to notification of revocation. Please see your Notice of Privacy Practices for information on how to revoke this authorization. I also understand that this authorization will automatically expire one year from the date of my signature unless I revoke it earlier. Anishinaabe Endaad will not refuse or revoke my treatment if I choose not to sign this authorization. A photocopy/fax of this authorization will be treated in the same manner as an original. You may, in the presence of Anishinaabe Endaad Staff, inspect or copy the information for use or disclosure with this Authorization for Disclosure.
I understand that substance use disorder records are protected under federal law, including the federal regulations governing the confidentiality of substance use disorder patient records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Parts 160 and 164, and cannot be disclosed without written consent unless otherwise provided for by the regulations.
Further, I realize that Anishinaabe Endaad cannot prevent the redisclosure of records released as a result of this request and that the records may not be subject to privacy rule protections; therefore Anishinaabe Endaad is released from any and all liability resulting from redisclosure.