Authorization to Disclose Protected Health Information
The undersigned authorizes to release my health information as noted below
I acknowledge and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, or AIDS information. Initial. (Please Initial)
1. I may refuse to sign this authorization and that it is strictly voluntary.2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization.3. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation. Unless otherwise revoked, this authorization will expire on the following date, event or condition: List Date 4. I understand that information used or disclosed pursuant to this authorization may be subject to re disclosure by the recipient and no longer be protected by Federal privacy regulations.