Consent for Release of Confidential Information

I understand that 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. I understand that I may revoke this authorization at any time upon written notice to PursueCare LLC. I acknowledge that such revocation will not be effective if PursueCare LLC. has already acted in reliance upon this authorization. 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: , or the completion of treatment, or at the time of the final insurance billing, as the case may be, whichever is later. 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.