I authorize the release of my complete health record, including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse.

This medical information may be used by the person I authorize to receive this information for medical treatment, consultation, billing or claims, insurance purposes or other purposes as I may direct.

I understand that I have the right to revoke this authorization in writing at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization, or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

I understand that information used or disclosed under this authorization may be disclosed by the recipient and may no longer be protected by law.