Cleveland Clinic DrConnect Operations 3175 Science Park Beachwood, OH 44112

Phone: 877.224.7367 (877.CCHS.EMR) Fax: 216.445.9668

I hereby authorize the Cleveland Clinic and its affiliates (collectively, "Cleveland Clinic") to release my health information as indicated below.

Information to be disclosed: I understand and agree that my treatment. The information released will include, but not be limited to, the following records:

will be released regardless of dates of

Alcohol and/or drug abuse treatment records Mental health treatment records including treatment for mental illness .HIV tests, results, diagnosis and treatment Discharge summariesHistory & physicalLaboratory reportsOperative reports .Pathology reports Medications Clinic/Progress notes Diagnoses

This authorization is subject to revocation at any time except to the extent the action has been taken thereon. I may revoke this authorization at any time by contacting Cleveland Clinic at the contact information listed above. I understand that the recipient of my health information may be charged for the service of releasing medical information.

This authorization will expire one hundred eighty-five (185) days from the date written below, unless I specify an earlier date: . I understand that information released pursuant to this authorization may remain part of my permanent medical record at Recipient. My health care (or payment for care) will not be affected by whether or not I sign this authorization. Oncemy health information is released, redisclosure of my health information by the Recipient may no longer be protected by law.

The information disclosed pursuant to this authorization will contain any and all information contained in my medical record that is protected by Federal confidentiality rules relating to treatment provided by Alcohol and Drug Abuse Program (42 C.F.R.Part2)andstate law pertaining to the disclosure of HIV/AIDS information. unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2 relating to the disclosure of alcohol and drug abuse program information or state law pertaining to disclosure of HIV/AIDS information. A general authorization for the release of medical or other information is NOT sufficient for these purposes. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

* Psychotherapy Notes are defined as notes that document private, joint, group, or family counseling sessions that are separated from the rest of a patient's medical record.

** If other than the patient's signature, a copy of legal paperwork verifying the patient's personal representative appointed guardian, durable power of attorney for health care For a deceased patient: A death certificate coupled with executor or administrator of estate paperwork must accompany authorization. Exception: parent signing for patient under the age of 18.

accompany the request (i.e. court