TO BE DISCLOSED TO:
Gould Farm - Admissions
PO BOX 157 Monterey, MA 01245
FAX - 413-645-1022
EMAIL - firstname.lastname@example.org
This information will be used/disclosed for the following purpose:
Assessment for possible admission to residential treatment program at Gould Farm.
I understand that I have the right to refuse to sign this authorization.
I understand that I may revoke this authorization, in writing, at any time. I understand that the revocation will not apply to information already released in response to this authorization.
I understand that I may inspect or copy any information used/disclosed under this authorization.
This authorization is valid for one year from the date it was signed OR for the duration of my treament by Gould Farm and the Boston Area Programs, whichever comes first.
The facility, it’s employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.