I understand that my alcohol and drug abuse patient records are protected under the Federal regulations governing confidentiality of those records, (42 CFR Part 2), cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand this Release expires 180 days from the date it is signed unless otherwise indicated by me. I also understand that I may cancel this Release at any time in writing with my signature, and the date it is signed, and delivering it to Cornerstone of Hope Lima. Canceling it applies to that day forward and not to information already shared.
I understand that signing or refusing to sign this Release will not affect public benefits or services for which I am eligible, unless otherwise required by the regulations of the agency.
I understand that the information disclosed pursuant to this authorization may be the subject of re-disclosure by the recipient without further protection.