I understand that the information relating to sexual transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavior or mental health services, and treatment for alcohol and drug abuse.

I understand that the information released is for specific purpose stated above. Any other use of this information without written consent of the patient

I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do SO in writing and present my written revocation to Woodlands Arthritis Clinic PA. I understand that this revocation will not apply to information already released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization expires in one year, I understand that authorizing the disclosure of this health information is voluntary.