I hereby authorize____________________________________ to disclose to Surgical Specialists of Alabama, LLC. my medical recordsand information pertaining to my medical history, physical history, services rendered or treatment of including, if any, psychiatric orpsychological information, infectious or contagious disease information, AIDS confidential information, and/or information about drugor alcohol abuse or treatment of the same.

By law, the HIPAA Privacy Rule prohibits Surgical Specialists of Alabama, LLC. from disclosing your Protected Health Information (PHI) to anyonewithout your authorization, except for treatment, payment, and health care operations. This rule became effective April 14, 2003.

By signing below, I give Surgical Specialists of Alabama, LLC. authorization to release my personal information as listed. I acknowledge thatI have received the attached Notice of Privacy Practices:

We believe everyone should have the opportunity for health. Some things like not having enough food or reliable transportation or a safe place to live can make it hard to be healthy. Please answer the following questions by circling YES or NO to help us better understand you and your current situation. We may not be able to find resources for all of your needs, but we will try and help as much as we can.