Release of Information

I authorize the following disclosing party to use or disclose the following information to PROSPERITY HAVEN TREATMENT CENTER.

These records may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases or mental health treatment.

This authorization is subject to written revocation at any time except to the extent the program or person who is to make the disclosure has already acted in reliance on it.

I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.

I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.