AUTHORIZATION TO RELEASE MEDICAL INFORMATION
I authorize Diveheart and its affiliates to disclose any and all of my medical information to my insurer and/or to Diveheart employees, officers, directors, agents, contractors, staff, volunteers, or assigns, Diveheart affiliates and/or dive boat operators, hotels, airlines, and travel agents as necessary to assure that I get the assistance I need when participating in a Diveheart Activity. To the extent applicable, I understand that my medical record may contain information that is considered sensitive under law, and hereby further authorize Diveheart and its affiliates to disclose HIV/AIDS, mental health, sexually transmitted disease, genetic, and alcohol and/or drug abuse information if such information exists in my records. I understand that my medical information is protected under the federal and state privacy laws and regulations, and cannot be disclosed without my written consent except as otherwise specifically provided by law. I understand that if the person(s) or entity(ies) that receives the medical information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and is no longer protected by those regulations. Therefore, I release Diveheart, its employees and my physicians from all liability arising from disclosure of my health information as authorized hereby. It is my understanding that this authorization will expire upon my discontinuation of participation in Diveheart activities. I understand that I may revoke this authorization by notifying Diveheart, in writing, but I understand that any such health information disclosed prior to the date of such written revocation request would not be subject to such revocation request.