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                    "text": "Information to be Released (Check All That Apply)",
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            "id": "p1.15",
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            "text": "5. Purpose for Disclosure (check All That Apply)"
        },
        {
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            "text": "_ Facilitate coordination of health care\n_ Academic Adjustment or Accommodations"
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            "text": "— Other (specify): _____",
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            "text": "I understand that I am giving my permission to the above named treatment provider or other named third party for disclosure of confidential health care information, including both records and discussions pertaining to those records, unless otherwise noted in Section 4 above. This consent is not a condition for treatment at the Kentucky State University Student Health Services or Counseling. I also understand that I have a right to revoke this consent, but that my revocation is not effective until delivered in writing to the person who is in possession of my records. A copy of this consent and a notation concerning the persons or third parties to who disclosure was made shall be included with my original records. The person who receives the records to which this consent pertains may be subject to re-disclosure by the recipient and no longer protected. I have the right to refuse to sign this authorization."
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            "text": "",
            "attrs": {
                "field_kind": "text",
                "source": "blank_line"
            }
        },
        {
            "id": "p1.21",
            "order": 53,
            "type": "footer",
            "bbox": {
                "l": 72.24,
                "t": 90.72,
                "r": 268.8,
                "b": 80.16
            },
            "text": "Signature of Patient (or parent/guardian if under 18)",
            "attrs": {
                "block_label": "footer"
            }
        },
        {
            "id": "p1.22",
            "order": 54,
            "type": "footer",
            "bbox": {
                "l": 358.08,
                "t": 90.48,
                "r": 538.56,
                "b": 79.92
            },
            "text": "Date (Document expires one year from this date)",
            "attrs": {
                "block_label": "footer"
            }
        }
    ],
    "excluded_furniture": {
        "first": [],
        "last": []
    }
}