The following documents/information from the records pertaining to services received date of service:
and that information will be handled confidentially in compliance with all applicable federal laws. I understand that I may see the information that is to be sent, and that I may revoke that authorization at any time by written, dated communication.
I have read and understand the nature if this release.
HIPAA PRIVACY ACT
45 CFR.524 (b) (2)