ROI McDowell Counseling & Associates, LLC Kearney, NE

McDowell Counseling & Associates, LLC is authorized to disclose/receive the following regarding:

I authorize McDowell Counseling & Associates, LLC

Organization or individual

Information to be released (check appropriate category)

Psychological Assessment

Drug and Alcohol Evaluation

The purpose of this disclosure is to:

I understand that I have a right to revoke this authorization at any time. I understand that a revocation will be made in writing and will not apply to information that has already been released in response to this authorization. I understand that a revocation will not apply to my insurance company when the laws provides my insurer with the right to contest a claim under my policy. Unless previously revoked this authorization will automatically expire six (6) months from date of discharge. I consider a photocopy of this authorization to be as valid as the original. This authorization is active for 12 months while in treatment, and will be renewed each year.

I understand that my records may include related drug and alcohol abuse information which is protected under the Federal Confidentiality Regulations (42 CFR, Part 2). Any further disclosure of my records other than what is outlined above is prohibited without my specific written consent, or otherwise permitted by such regulations.

I further acknowledge that the information being released was fully explained to me and this consent is given willingly.

(Signature of Patient/Guardian)

(Signature of witness)