|Alabama and federal law
requires that information contained in your medical records be held in strict confidence and not be released without your
The consent you sign on this form will remain in effect until you request in writting that your consent be
withdrawn, which you may do at any time. You have a right to request and obtain a copy of this consent. This form is intended
for Special Needs Registration Purposes only. Dissemination, distribution, or copying of this form is strictly prohibited except
by use by authorized persons. The original of this form shall be secured in a locked file.