2. Redisclosure: I/we understand that information used or disclosed in accordance with this authorization may no longer be protected by federal law, and could be used or redisclosed by the receiving party, pursuant to any agreement I may have with such party.
3. Refusal to sign: I/we understand that I/we may refuse to sign this authorization and the result would be that the records would not be disclosed.
4. Certification: The undersigned affirms that the identification that I have provided is true and correct.
5. Revocation: I/we have the right to stop the use or release of this information at any time if I do so in writing to Coping Partners although I/we understand that I/we cannot do anything about information already used or disclosed pursuant to this authorization.
6. Copy Received: I/we understand that I/we will receive a copy of this completed form.
7. Inspect and Copy: I/we understand that I/we have the right to inspect and copy the information to be disclosed.
8. Challenge: I/we understand that I/we have the right to challenge the accuracy of any information contained in the subject file.
9. Effect of Copies: I/we intend that fax, copies or electronic versions of this document shall carry the same force and effect as the original.
10. Alcohol/Substance Abuse Files: If any requested records contain information regarding alcohol or drug abuse treatment, these records are protected by Federal confidentiality rules. These rules prohibit further disclosure of this information unless further use or disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by Federal rules. A general authorization for the use or release of medical or other information is insufficient for this purpose. Federal rules restrict use of the information for criminal investigation or prosecution of any alcohol or drug abuse patient.