Disclosed information is protected by Federal Rules governing confidentiality rules (42 CFR part 2 The Federal Rules prohibit recipients from making any further disclosure of this information unless the subject of the material provides additional written permission (42 CFR Part 2 This general authorization for the release of medical or other information is not sufficient for this purpose. Also, Federal Rules restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse patient.
I had the opportunity to ask questions and they have been answered; I understand all information contained in this document.
I voluntarily authorize the information specified above to be obtained from or released to PTP; it will be held in strict confidence. I understand my information cannot be re-released by a recipient without my written consent. I understand this authorization will remain in effect until I specify an expiration date. If I have questions concerning any of this content in the future, I will ask my clinician.
I release PTP from any legal responsibility that may arise from the release of the above requested information.