Patient Authorization for use and disclosure of protected health information

1. Authorization: By electronically signing this authorization, I authorize the privacy officer to use and/or disclose to the following person or entity the following protected health information ("PHI"):

(a) Disclose PHI to:

Remmel Wellness Center
6416 Dr. Martin Luther King Jr. St. N.
St. Petersburg, FL 33702
p 727-525-1141 / f 727-525-1195

2. Purpose: This authorization is granted for treatment and evaluation of:

If you have initiated this authorization and its purpose is different than above and wish to not disclose please select "yes."

3. Expiration: This authorization is valid until termination of treatment with RWC. If date of termination is not same as above please idicate below.

4. Limitations: In addition to the above, the following are other criteria or limitations that I impose regarding this authorization.

5. Voluntary: I acknowledge this authorization is voluntary.

6. Pre-Conditions: I understand that RWC may not condition treatment based on this authorization.

7. Revocation: I understand that this authorization may be revoked by me at any time, provided that I submit a signed revocation form to RWC's Privacy Officer. However, any revocation shall not apply to the extent that the RWC has taken action in reliance of this authorization.

8. Re-disclosure: I understand that the information used or disclosed pursuant to this authorization may be re-disclosed by the recipient, and that the information will no longer be protected by the RWC or the HIPAA Privacy Rules.

9. Copy of Authorization: If the RWC has requested this authorization from me, I understand that the RWC will provide me a copy of this authorization once signed by me.

Electronically sign and date below.