I, the undersigned patient, hereby voluntarily authorize the disclosure or use of my health information as follows.

 

Information may be disclosed/obtained: Mail, In-Person, Phone, E-Mail or by Fax, unless specified.

The information to be disclosed from my record (mark all applicable) Only information relating to: Only information for these dates: Other:

*Except for records relating to alcohol or drug use, sexually transmitted diseases, genetic testing, HIV/AIDS-related conditions, and psychiatric or mental health conditions. To authorize the disclosure of these records, check the applicable boxes below.

*Attention* Mental Health Records require express authorization*

The following records will not be disclosed without your express consent. Please mark any that you expressly authorize to be disclosed. Alcohol or drug use Sexually transmitted diseases Genetic testing HIV/AIDS-related conditions Psychiatric or mental health conditions

I understand that I may revoke this authorization in writing, except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will terminate one year from the date of my signature unless I provide an alternative expiration: I, the undersigned, hereby authorize the disclosure of my health information as I have indicated above by checking the applicable box(es), including, if checked, records relating to the following treatments or conditions: alcohol or drug use, sexually transmitted diseases, HIV/AIDS-related conditions, genetic testing, and psychiatric/mental health conditions. I understand that information disclosed by this authorization may be subject to redisclosure by the recipient. Rainbow Mental Health PLLC will retain the original form.

Witness and/or Parent in case of Minors:

Rainbow Mental Health, PLLC Release of Information