Periodic Use/Disclosure: I authorize the periodic use/disclosure of the information described below to the person/provider/organization/facility/program(s) identified as often as necessary to fulfill the purpose identified in this document. My authorization will expire when I am no longer receiving services from Hope 419 or 2 years after submission. 

I understand that: 

• I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment. 

• I may cancel this authorization at any time by submitting a written request to Hope419. 

• If the person or facility receiving this information is not a healthcare or medical insurance provider covered by privacy   regulations, the information stated above could be redisclosed. 

• If the authorized information is protected by Federal Confidentiality Rules 42CFR, Part 2, it may not be disclosed without my written consent unless otherwise provided for in the regulations. 

• Release of HIV-related information requires additional information. 

• If the medical record information is not sent to another care provider, there may be a charge of the requested records. 

*Rule 5122-27-06: The provider will not condition treatment, payment, enrollment, or eligibility on client's authorization for the release of information, or a statement of the consequences to the client if client refuses to sign an authorization for the release of information.