Authorization for Exchange of Confidential Information

A. The names of parties exchanging information

I authorize:

Such information may be freely exchanged by the above-designated parties in writing (by fax, electronic mail, or other electronic file transfer mechanisms), by postal delivery, in person, or by telephone, but such exchange is limited to the agencies or people listed and to necessary information related to care and treatment of individual, unless otherwise specified. I release the parties involved from all liability arising from such exchange of information. I accept full responsibility for any and all action or consequences that may directly or indirectly result from the release of this information. I understand that this release of information is intended to allow me to provide my informed consent for an exception to my confidentiality and the protection of my privacy guaranteed under federal law, including, but no limited to, the Federal Privacy Act (P.L. 93-579), the Freedom of Information Act (P.L. 93-502), and the Code of Federal Regulations (42, Part 2).

There the potential for information disclosed pursuant to this authorization to be subject to redisclosure by the recipient and no longer be protected by a subpart of federal regulation. You may revoke this authorization at any time except to the extent that the program instructed to make the disclosure has already taken action in reliance on it. Please notify us in writing of desire to revoke authorization.