I understand this authorization will remain in effect for the duration of my treatment. I may revoke this authorization at any time by written request. A photocopy of this release will be accepted as comparable to the original.
I further understand that federal law prohibits disclosure of matters concerning regulated substances
(such as illicit drugs and/or alcohol) without explicit written consent regarding such matters. HIV-related
information and drug and alcohol information will be released under this consent unless indicated here:
