Authorization to Release / Exchange Information | Heart of Care Full Spectrum CTS

I, the person named below, authorize The Ninety-Nine Retreat, LLC dba Heart of Care Full Spectrum Community Treatment Service to release information about me to — and receive information from — the person(s) or organization(s) listed. This authorization is HIPAA-ready and, where 42 CFR Part 2 protected substance-use information is disclosed, includes the notice required by 42 CFR Part 2. Purpose of disclosure: care coordination, benefit access, family support, legal/court coordination, education, or other purpose I list below. I understand: • I do not have to sign this form. Refusal will not affect my ability to receive services from Heart of Care. • I may cancel this authorization at any time in writing, except for information already released in good-faith reliance on it. • Information released may be re-disclosed by the recipient and may no longer be protected by federal privacy law. • If not revoked sooner, this authorization expires one (1) year from the date signed, or on the date I list below.