I, the above-named patient, hereby request and authorize any physician, hospital or other medical provider to release to the staff and providers of MEDICAL RESEARCH GROUP OF CENTRAL FL any information regarding my medical history, symptoms, treatment, exam results or diagnoses. I hereby consent to the release of the above information regarding my treatment, and/or outpatient care for my impairments, including psychological or psychiatric impairment(s), drug and alcohol abuse, or HIV/Transmitted disease. I understand that I may revoke this Authorization at any time prior to the expiration date or event, but that my revocation will not have any effect on actions taken by the above-named healthcare provider(s) or its physicians, employees or agents before the healthcare provider(s) received my revocation. Should I desire to revoke this Authorization, I must send written notice to the healthcare provider(s). I understand that I am not required to sign this Authorization. I understand that my records may be subject to disclosure by the recipient and may no longer be protected by federal privacy regulations. I understand that this Authorization does not limit the above-named healthcare provider(s) or its physicians, employees or agent’s ability to use or disclose my information for treatment, payment, or healthcare operations, or as otherwise permitted by law. This authorization is valid for three years unless otherwise revoked. I give this consent voluntarily.