RELEASE OF INFORMATION (ROI)

This Authorization permits the disclosure and/or exchange of confidential information under Massachusetts and Connecticut law and applicable federal law. Read carefully. Ask questions before signing.

Required notices

• We will not condition the provision of treatment, payment, or eligibility for benefits on whether I sign this authorization form.

• This form must be completed fully or it will not be valid.

• I have the right to revoke this authorization. If I choose to exercise this right, revocation must be in writing.

• After my information is released, the recipient may re-disclose it and it may no longer be protected by federal law.

• I am entitled to receive a copy of this authorization.