I hereby authorize the above physician/facility to release my individually identifiable health information as outlined below to:
TLC Family Health (Flower Mound, TX, Phone: 972-914-9421, Fax: 915-331-9481)
which may include information such as Human Immunodeficiency Virus (HIV) status and Acquired Immune Deficiency Syndrome (AIDS), mental illness (except psychotherapy notes), chemical or alcohol dependency, laboratory and imaging reports, medical history, treatment, and related information. I understand that this authorization is voluntary.