• My signature below signifies that I understand that I am authorizing an extension of the original consents signed for:

  • So that the above-mentioned client may continue to receive services with H.E.A.D.S. for a period ending on
  • (one year from date of original consents)
    Date Format: MM slash DD slash YYYY
  • I understand that this consent is valid for one year and that I have the right to rescind this consent at any time.

    You have the right to revoke this authorization, in writing, at any time per HIPAA Privacy Policy 164.520, with the exception of those authorizations you signed for routine disclosures for treatment, payment or healthcare operations as permitted by the HIPAA Privacy Rule. HEADS will not condition your treatment, payment, enrollment or eligibility on whether or not you sign this release of information. Be advised that there is potential for your information to be redisclosed by the recipient and no longer protected by 45 CFR, Part 164, Subpart E.