AUTHORIZATION TO USE AND DISCLOSE INFORMATION FOR ALUMNI OUTREACH

authorize Ashley Addiction Treatment (“Ashley”) to use my name, address, email address and telephone number for the purpose of alumni outreach which includes marketing and fundraising for Ashley. I further authorize Ashley to disclose my name, address, email address and telephone number to its third party vendor that assists with alumni outreach including marketing and fundraising for Ashley. I understand that my records are protected under federal confidentiality regulations (42 CFR Part 2) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and cannot be used or disclosed without my written consent unless otherwise provided for in the regulations. By signing below, I authorize and consent to Ashley using and disclosing my information as described above. I also acknowledge, agree, and understand the following:

• Right to Revoke. Except to the extent action has already been taken in reliance on this Authorization, I can, at any time, revoke (take back) this Authorization by submitting a notice in writing to Ashley Addiction Treatment, Health Information Management, 800 Tydings Lane, Havre de Grace, MD, 21078 or medicalrecords@Ashleytreatment.org . Unless I revoke this Authorization prior, this Authorization will remain in effect as long as Ashley conducts alumni outreach.

• Electronic Disclosures. Disclosures of my information pursuant to this Authorization may occur via electronic means. I understand that electronic communications may not be secure.

• Authorization Not a Condition to Treatment. I understand Ashley cannot require me to sign this Authorization in order receive treatment.

• Copy. I understand that I have a right to a copy of this Authorization.

I have read and understand this Authorization and all my questions have been answered.