Consent for the release of confidential information

(Name)

I understand this consent is subject to written revocation by the undersigned at any time except to the extent that action has already been taken to receive the information. This consent shall automatically expire one year from the date signed, unless otherwise specified below.

TO THE PARTY RECEIVING THIS INFORMATION: This information has been disclosed to you from the records whose confidentiality maybe protected by federal law. Federal Regulations (42CFR Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. FOR PATIENT RECORDS APPLICABLE UNDER FEDERAL LAW 42 CFR PART 2.

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