Check Confidential Information to be Released or Obtained:
I have read carefully the above statements and do voluntarily consent to disclosure of the above information (including alcohol, and drug treatment, and HIV (AIDS) related records) and/or Medical, School Records to those persons or agency named above. I understand that my records are protected under the Federal Confidentiality regulations (42CRF part 2) published July 1, 1975, and/or the General Laws of the State of Rhode Island, cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that if I authorize Ronitte Vilker, Ph.D. to disclose information, the recipient of the information might disclose it to others, and that information disclosed by Ronitte Vilker, Ph.D. may no longer be protected by the federal rule on the privacy of medical records. I also understand that I may withdraw or revoke this consent (in written revocation) at any time except to the extent action has been taken in reliance on it (e.g. probation, parole, etc.) and that in the event this consent expires automatically as described below:
This consent expires in one year from date signed.