AUTHORIZATION FOR USE, DISCLOSURE, AND/OR EXCHANGE OF MEDICAL & MENTAL HEALTHINFORMATION INCLUDING PRIVATE HEALTH INFORMATION UNDER HIPAA AND CONFIDENTIALALCOHOL AND SUBSTANCE ABUSE TREATMENT RECORDS UNDER 42 C.F.R, PART 2

NATURE AND LIMITS OF INFORMATION TO BE DISCLOSED:

I hereby authorize Behavioral Health Clinic (BHC)to release the following information contained in my provider records, including confidential alcohol and substanceabuse treatment records, inclusive of medical, mental health and other identifying information and confidentialcommunications, any medical records and mental health records as described or defined under Maryland statutory orcase law, private health information (PHI) under HIPAA, and, if checked off and initialed in the table below, otherinformation pertaining to my treatment at the above-named facility/provider (all hereinafter collectively “information”).This request authorizes the release, exchange and disclosure of the following information contained in my files. Ispecifically request the disclosure or non-disclosure of the following information.

DISCLOSURE TO BE MADE TO/INFORMATION EXCHANGED WITH:

Expiration Date/Revocation

This authorization automatically expires one year from the date signed below unlessrevoked in writing sooner by the individual authorizing disclosure in written form to the person or entity to whom or which thedisclosure is or was to be made. Revocation for criminal justice referred substance abuse clients is prohibited pursuant to theconditions of 42 C.F.R. Part 2 §§ 2.31 and 2.35. I understand I can ask the court to limit re-disclosure thereafter.

REDISLOSURE/WAIVER:

I also authorize the intended recipient to re-disclose and/or use all or part of the information obtainedfor purposes of Continuance of Care. I understand that the protected information herein may only be re-disclosed to those personsor entities specifically designated herein without further protection under HIPAA, Maryland statutes and federal confidentialityregulations for alcohol and substance abuse under 42 C.F.R. Part 2. MISCELLANEOUS: A photocopy or facsimile of thisauthorization and request for release of information shall be deemed as valid as an original. I understand that information may bereleased in reliance hereon to the extent revocation has not occurred. I understand that benefits may not be conditioned upon signingthis authorization.