ATTENTION: If the client is 18 years of age or older, the client must sign and date this form. If the client is 18 years of age or older and incapable of signing, a legally authorized substitute or legal guardian may sign and date this form. If the client is 17 years of age or younger, the client's parent or legal guardian must sign and date this form, unless an exception exists under state or federal law.

I understand that documents and/or information sent via email may not be secure. Hope Springs Behavioral Consultants puts the security of the client at a high priority. Unfortunately, full security of email messages cannot be ensured as, despite our efforts, the data included in emails could be infected, intercepted, or corrupted. Therefore, the recipient should check the email for threats with proper software, as the sender does not accept liability for any damage inflicted by viewing the content of the email.

I authorize Hope Springs Behavioral Consultants to disclose information to and/or obtain information from the below person, provider, clinic, school, and/or other designated entity. This authorization will be valid for one (1) year from the date of submission.

FORM OF DISCLOSURE
Unless you have specifically requested in writing that the disclosure be made in a certain format only, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law and/or ethical standards of the psychology profession, including, but not limited to: verbally, in paper format, or electronically.  I understand that I may talk to my provider at any time if I have questions about this document.

REDISCLOSURE
Disclosure of this information carries with it the potential for unauthorized re-disclosure, and once information is disclosed it may no longer be protected by federal privacy regulations. This form does not authorize re-disclosure of medical information beyond the limits of the consent.  I understand that I may review the disclosed information or ask questions by contacting Hope Springs. I may be charged for copies in accordance with state law.

REVOCATION
I understand the information to be disclosed may include records related to behavior and/or mental health, test data, alcohol/drug abuse treatment, HIV/AIDS, and genetics. This authorization may be revoked at any time except to the extent that action has been taken in reliance upon it. I may do so by sending written notice to Hope Springs Behavioral Consultants, 1303 5th Street, Suite 202, Coralville, IA 52241-2939. I understand that any release that was made prior to my revocation in compliance with this authorization shall not constitute a breach of my rights to confidentiality.

EXPIRATION
This agreement will expire one year from the date of signature, unless previously revoked or otherwise indicated.

CONDITIONS
I understand that Hope Springs Behavioral Consultants does not require completion of this form as a condition of treatment. However, when the provision of services is solely for the purpose of creating a medical report for review of a third party, refusal to sign may result in a denial of those services.

ATTENTION: This is a legal document. By signing, I agree to, understand, and accept the terms of this authorization. If records are inadvertently received by an unauthorized recipient, through no fault of the sender, I waive claim against the sender.