LIFE MANAGEMENT FOR ADULTS, PLLCPATIENT AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
I authorize Life Management for Adults (“LMA”) to use or disclose the above-named individual's health information as described below.
1. This information may be disclosed to, and used by, the following individuals or organizations:
2. The type and amount of information to be used or disclosed is as follows (check off the appropriate item(s), and include other information where indicated)
This authorization may extend to the release of records related to ALCOHOL ABUSE, DRUG ABUSE, SEXUALLY TRANSMITTED DISEASES, PSYCHIATRIC, AND/OR HIV DIAGNOSIS AND TREATMENT. The information obtained herein is confidential and must be used for the purpose it was requested any may not be re-released. The date of this authorization must not precede the date(s) of service that is requested.3. This information is being disclosed for the following purpose(s): purpose of release .
4. Methods of disclosure authorized: Faxed, written, phone conversation, in person and/or secure e-mail5. Patient Acknowledgments: