(Please read this carefully and sign at the bottom)
We cannot discuss your program, progress or health information with anyone—not even your spouse or loved ones—without written permission.
Submit the form below to tell us with whom and what we can share. Think ahead to your treatment and submit as many times as you need. For instance, Spouse, Loved One, Doctors, Attorney, Parole Officer or person paying for your treatment should each be submitted separately.
One form per one person or organization.
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