I hereby consent and authorize any drug, alcohol and/or addiction treatment program owned or operated by Bradford Health Services, LLC and/or its parents, subsidiaries, and/or affiliates, and/or any other drug, alcohol and/or addiction treatment program I have selected to receive services from to release to and/or to obtain from Bradford Cares the consultation related to prospective substance use disorder treatment services, including my use history and substance of choice; treatment recommendation(s), including level of care and length of stay; information concerning my discharge, including dates of discharge and whether treatment was successfully completed according to treatment plan and/or recommendations; and the protected health information contained with the aforementioned elements of information/documentation, including my name, demographic information (consisting of date of birth, social security number, gender, and race) , contact information, and insurance/financial information. The information I am authorizing to be disclosed pursuant to this authorization will be disclosed for purposes of determining my eligibility for assistance from Bradford Cares and coordination of payment for treatment services (should assistance be awarded).

I understand that I may revoke this authorization at any time, in writing, by notifying the Administrator of Bradford Cares and/or the designated personnel of my treatment provider. I understand if I revoke this authorization, it will not have any effect on uses or disclosures made prior to the receipt of the revocation. I understand that this authorization is voluntary, and that I may refuse to sign this authorization, which will have not affect my treatment and/or payment unless either of the following applies: the treatment is related to research and the use and/or disclosure is related to such research; or the treatment is solely for the purpose of creating protected health information for disclosure to a third party. I understand the potential for records and/or information disclosed pursuant to this authorization to be redisclosed by the recipient. I understand that treatment providers may not condition treatment, payment, or eligibility of benefits on my signing this authorization. Unless revoked or otherwise specified by the signatory in writing, this authorization has no expiration.