The specific PHI to be used/disclosed shall include only the minimum information necessary to assist in the above stated purpose.
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I understand the information to be used/disclosed may be communicated in written, verbal, or electronic form.
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I understand that substance use information is protected by federal regulations and cannot be released without my authorization (above).
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I understand the information to be used/disclosed may contain HIV/AIDS information.
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In accordance with the doctrine consent, I understand the consent of the information to be used/disclosed, the need for the information, and that there are statutes and regulations protecting the confidentiality of authorized information.
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Redisclosure of protected health information in prohibited except as permitted or required by state or federal laws.
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I understand that I may revoke this consent in writing at any time except for those actions taken prior to revocation.
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I understand that I may refuse to sign this authorization form.
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I hereby acknowledge that this consent is truly voluntary.
By signing my name and printing the date in the boxes below, I hereby consent to the terms of this document.