All information I hereby authorize to be obtained from this agency will be held in strictly confidential and cannot be released by the recipient without my express written consent.
I understand that this authorization will remain in effect for 1 (one) year unless I specified an earlier date above.
I understand that the information used or disclosed may be subject to disclosure by the person(s) or class of person(s) receiving it and no longer protected by the federal privacy regulations.
I understand that my confidential information may be released to the adoptive family in a non-identifying manner.
I understand that I may withdraw this consent at any time as long as the request is made in writing to the above listed medical provider. However, I understand that if I revoke this authorization, it will not have effect on action taken by the above medical provider in reliance on it before my revocation.
I also understand that refusal to sign this authorization will not prevent my ability to get treatment, payment, enrollment in a health plan, or eligibility for benefits.