January 19, 2016

Enroll

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I agree that all this information is correct. I also authorize StepHouse Recovery and StepHouse Alumni to contact me after discharge from treatment. I also authorize that I, myself, can contact StepHouse Recovery/StepHouse Alumni before, during, and after being part of the Alumni Program. I declare this consent is given freely and voluntarily, and I understand my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, as well as under HIPAA, 45 CFR Parts 160 and 164, and that no information may be disclosed by either party to any individual or agency unless by written consent of the patient. I also understand that this authorization may be revoked at any time in the future by written statement.