I understand the information being released may contain sensitive private health information (sPHI): behavioral or mental health services, treatment for alcohol and drug abuse, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) or drug and alcohol abuse treatment and that Federal and State laws expressly prohibit disclosure without the specific written consent of the person served, legal guardian and/or parent (if a minor). furthermore, I understand the information may be released in written, verbal, video, audio, or electronic format. I understand that this authorization, except for action already taken, may be revoked or voided by me at anytime, by advising the privacy officer in writing at the address below. If not previously revoked or voided, this consent will expire one year from the date of signature. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that information used or disclosed under this authorization might be redisclosed by the recipient and no longer protected by federal confidentiality rules. If I have any questions about disclosure of my health information, I can contact the NeurAbilities Privacy Officer at compliance@neurabilities.com .