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The above information will be used for the following purposes

Continuity treatment -Patient History -Case Management services Emergency contact -General Updates Court services -Legal Purposes -Probation -Disability Claiming Other

My records are protected under Federal Confidentiality regulations (42 CFR Part 2) published August 10, 1987, and the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. Section 1320d, et. Seq and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that my medical record may contain information concerning my psychiatric, psychological, drug or alcohol abuse, HIV/Acquired Immune Deficiency Syndrome (AIDS), and/or related conditions.

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I may revoke this authorization at any time upon written notice to Emerald Psychiatry. I acknowledge that such revocation will not be effective if Emerald Psychiatry has already acted in reliance upon this authorization.

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This authorization is valid (if not previously revoked) this consent will terminate upon 90 days from the date of signature of this form, or the following event/condition: (PLEASE EXPLAIN IN OTHER BELOW), or the completion of treatment, or at the time of the final insurance billing, as the case may be, whichever is later.

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PROHIBITION ON RE-DISCLOSURE: This information has been disclosed from records protected by Federal Confidentiality Rules (42 CFR part 2). The Federal rules prohibit making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.

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