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The form requires identification of the person, contact details, ID numbers, disclosure purpose, recipient, and expiration terms. It explains revocation rights, refusal to sign, and that release does not condition services. 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I authorize the Department of Human Services to use/disclose individual information as  \ndescribed below from the records of:  \nName:    \nDate of Birth:   Telephone:    \nAddress:   ID number(s) (identify each type of number)   \n2. Reason for disclosure:    \n(Describe each specific purpose- if disclosure is at individual’s request and information to be disclosed does not include drug and alcohol treatment information, may state,“At the request of the individual”)  \n3. I understand that:  \na. this authorization may be revoked at any time by writing to the individual/organization identified in section 1 except to the extent that information has already been disclosed. If information has already been disclosed in reliance on this authorization, revoking it will only prevent future disclosure.  \nb. the Department and its health and human services programs will not condition treatment, payment, enrollment or eligibility on the provision of this authorization.  \nc. information (except drug and alcohol information) disclosed pursuant to this authorization may be subject toredisclosure by the individual/organization identified in section A.2 below and is no longer protected by federal privacy regulations.  \nd. the Department, its programs, services, employees, officers, and contractors are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized.  \ne. I may refuse to sign this authorization.  \nPART A -General Information  \nA.1 Information to be disclosed and time period of information requested (Identify specifically the informa  \ntion to be used/disclosed such as welfare records, lien records, inspection records, etc. If information tobe used or disclosed includes mental health, drug and alcohol, or HIV-related information, please complete section of this form that relates to that information):  \nA.2 This information is to be disclosed to:  \n(Insert name or title of the individual/organization to whom disclosure is to be made)  \nA.3 This authorization expires as indicated:  \nOnce acted upon  \n  Other (specify date or event)    \nHS 1815 12/17  \nPART B -Special Categories of Medical Information  \nB.1  Drug and Alcohol Information  \nIf my medical record includes drug and alcohol information, I want to send that information to the  \nindividual/organization identified in Part A of this form.  \n  Yes   No or Not Applicable  \nThis information will be disclosed from records protected by Federal Confidentiality rules (42 CFR Part 2) .  \nThe Federal rules prohibit the individual/organization identified in Part A of this form from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. 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 or prosecute any alcohol or drug abuse patient.  \nB.2  Mental Health Information  \nIf my medical record includes mental health information, I want to send that information to the  \nindividual/organization identified in Part A of this form.  \n  Yes   No or Not Applicable  \nB.3  HIV/AIDS Information  \nIf my medical record includes HIV/Aids information, I want to send that information to the individual/organization identified in Part A of this form.  \n  Yes   No or Not Applicable  \nThis information will be disclosed from records protected by Pennsylvania law. Pennsylvania law prohibits further disclosures of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, or is authorized by the Confidentiality of HIV-Related Information Act. A general authorization for the release ","cbCaibZZcdNNXf5W","https://ap.wps.com/l/cbCaibZZcdNNXf5W","pdf",633415,"English","# Authorization for Use or Disclosure of Personal Information\n## General authorization terms\n## Part A - General Information\n## Part B - Special Categories of Medical Information","[{\"question\":\"Are drug and alcohol, mental health, and HIV/AIDS disclosures treated differently?\",\"answer\":\"Yes. The form includes special sections requiring specific consent and explains additional federal (42 CFR Part 2) and Pennsylvania confidentiality restrictions that limit further disclosure and certain uses.\"}]","Authorization for Use or Disclosure of Personal Information | PDF",1789617978]