I, blanks hereby authorize the use or disclosure of my protected health infomation as described below. 1. AUTHORIZED PERSONS TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
INITIALS: blankI authorized to disclose the following protected health infomation to Little Hands and Creations.

1. DESCRIPTION OF INFORMATION TO BE DISCLOSED

The health information that may be disclosed are:
Medical records
Communicable diseases (including HIV and AIDS)
Alcohol/drug abuse treatment
Mental health records
All treatment records

All past, pressent, and future periods of health care information may be shared.

1. PURPOSE OF THE USE OR DISCLOSURE

The purpose of this use or disclosure is to ensure all information is kept private.

1. VALIDITY OF AUTHORIZTION FORM

This Authorization Form is valid beginning on date signed below and expires at the end of services

1. ACKNOWLEDGEMENT

I understand that the information used or disclosed under this Authorization Form may be subject to re-disclosure by the person(s) or facility receiving it and would then no longer be protected by federal privacy regulations.
I have the right to refuse to sign this Authorization Form. If signed, I have the right to revoke this authorization, in writing, at any time. I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect these actions.