Authorization to Exchange Information

I, freely give consent to Crossroads, Inc. and the informant to exchange the Person’s Name (self if over 16 in MD or legal guardian) below noted information for the purpose of payment, facilitating treatment, and continuity of care for me/for my child.

This consent to release information is given freely, voluntarily, and without coercion, and be withdrawn by me at any time. Any information I authorize other professionals to release to Crossroads, Inc. will be held strictly confidential and will not be released without my written permission except as permitted by State or Federal law. I understand that I have the right to inspect the record or mental health information on the above-named individual. The information to be disclosed may include information about medical conditions, including HIV/AIDS and substance abuse, which is pertinent and relevant to the facilitation of treatment.