HEALTHY HEALING

COUNSELING, INC.

Authorization to Release Information

This authorization is only valid for the purpose stated below. Healthy Healing Counseling, Inc. (HHC) must obtain written authorization before requesting or disclosing any additional information from or to any other person or agency.

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I hereby authorize Healthy Healing Counseling, Inc. To:

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Please indicate Yes or No to the following provisions

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This release will be valid from/to
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(not to exceed one year)

This release will automatically expire upon discharge. I understand my rights to revoke this authorization at any time.

I understand that the information indicated is protected by law and cannot be released without my written consent unless otherwise permitted by law. My signature below indicates that I have read this release and have had the benefits, risks, and consequences of releasing or not releasing information explained to me. I understand that I have a right to review all materials prior to their release to or from HHC, Inc. and that the materials to be released will be reviewed with me upon my request. I understand that I do not need to sign this form to receive services and that I may review HHC, Inc's Notice of Privacy Practices before I sign this form.

Mental Health Information: This information has been disclosed from records protected by Maine Statue for confidentiality of mental health information (34-8 MRSA) This information should not be disclosed any further without the specific written consent of the person to whom it pertains, or otherwise permitted by law. Substance Abuse Information: This information has been disclosed from records protected by Federal confidentiality rules (42 C.F.R Part 2). Federal regulations prohibit any further disclosure without specific written consent of the person to whom it pertains, or other wise permitted by such regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate any alcohol and drug abuse client.

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"Challenges are what make life interesting and overcoming them is what makes life meaningful" - - Joshua J. Marine