Authorization to Release Confidential Record and Information

Date of the Birth(Required)

I understand this release is voluntary and applies to all programs and services operated under the auspices of BEHAVIORAL SOLUTIONS, LLC. I understand that my personally identifiable information (PII) may be protected by the federal rules for privacy under the Family Educational Rights and Privacy Act (FERPA), the Health Insurance Portability and Accountability Act (HIPAA), and/or other applicable state or federal laws and regulations. I understand that my PII may be subject to re-disclosure by the recipient without specific written consent of the person to whom it pertains, or as otherwise permitted. I also understand that the recipient may not condition treatment, payment, enrollment or eligibility on whether I sign this form, except for certain eligibility or enrollment determinations. I understand that I may revoke this authorization at any time by notifying BEHAVIORAL SOLUTIONS, LLC in writing but if I do, it will not have any effect on any actions taken before receipt of the revocation.

Specify Other(Required)

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The purpose if this release is:(Required)

Signature of Student/ Consumer/ Patient or Legally Authorized Representative(Required)

PRINT NAME and Relationship of Legally Authorized Representative to Student/ Consumer/ Patient(Required)

Date(Required)

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