To release and obtain healthcare/legal information to/from the following lawyer (and law firm staff):

I understand the following:

• The release of "all healthcare information" includes information regarding mental health treatment; drugs and alcohol use; and communicable diseases, such as HIV/AIDS and all others.
• I have the right to inspect and obtain a copy of the records that are to be disclosed. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.
• This authorization is voluntary. I understand that the person(s) / organization(s) authorized to make requested use and/or disclosure may not condition the provision of treatment on the provision of an authorization.
• I may revoke this authorization at any time. I understand if I revoke this authorization, I must do so in writing and present my written revocation to the office authorized above to make the release. I understand the revocation will not apply to information that has already been released in response to this authorization.