I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I have read the notice of Confidentiality of Alcohol and Drug Abuse Patient Records provided to me by OCOK.
I also understand that I may revoke this consent at any time except to the extent that action already has been initiated in reliance on the released information. I may revoke this authorization at any time by giving notice to the provider(s) listed above that I do not consent to the release of any further information. I also understand that a provider cannot condition treatment, payment, enrollment, or eligibility for benefits based on whether I sign this form. If I have not revoked it earlier, this consent expires automatically one year from the date I sign this form, or when the following event or conditions occur: .
(Please provide specifics of the date, event, or condition upon which this consent expires. For example, “Upon conclusion of any court proceedings regarding my children in which OCOK is a party.”)