Authorization for Use and Disclosure of Protected Health Information

*I authorize the person or organizations named below to disclose information to Kent Youth and Family Services.

(Please check each specific authorization)

This authorization is subject to revocation at any time, unless the agency has already disclosed the information. If not previously revoked, this consent will terminate in ninety (90) days from the signature date or upon the individuals discharge from services, whichever is longer.

REDISCLOSURE PROHIBITED: This information has been disclosed to you from records whose confidentiality is protected by state or federal law. These laws prohibit you from making any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by state law. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

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