ACE Release of Records

I authorize Alternative Consulting Enterprises, LLC (ACE), to obtain or disclose information from my medical record, which may include information about my psychiatric diagnosis, treatment, and mental health.

By signing below, I acknowledge that I have read and understand the following:

1. I understand that this authorization will expire one year from the date of the signature unless withdrawn.
2. A photocopy of this authorization shall be considered as the original.
3. I understand that I may revoke this authorization at any time by submitting a formal written request to ACE so that this authorization shall no longer be effective except to the extent action has already been taken upon it.
4. I understand that information disclosed or used pursuant to this authorization may be subject to re-disclosure but only in compliance with Federal privacy regulations and any State or Federal laws prohibiting the disclosure of PHI.
5. I understand that my refusal to sign this authorization will not jeopardize my right to obtain present or future treatment except where disclosure of information is necessary for treatment.
6. I understand that I may obtain a copy of this form after it is signed by all parties.
7. I understand that I am authorizing the release of my records to initiate or continue treatment in order to sustain continuity of care.