I hereby authorize the above physician/practice/facility to release my individually identifiable health information as outlined below to:
Direct Family Care of Northern Colorado
(Fort Collins, CO, Ph 970-632-4931, F 888-939-4124)
126 W. Harvard St. Suite 1, Fort Collins, CO, 80525
which may include information concerning such as laboratory and imaging reports, medical history, treatment, and any other such related information. I understand that this authorization is voluntary and I may refuse to sign it. I further understand that my health care and the payment of my health care will not be affected if I do not sign this form, and I will be provided a signed copy of the form if requested. I understand written notification is necessary to cancel this authorization. To obtain information on ot to withdraw my authorization or to recieve a copy of my withdrawal I may contact Direct Family Care at 970-632-4931. I am aware that the revocation will not apply to inforamtion that has already been released in response to this authorization.