Release of Information Authorization

YourTime Psychiatry and Medical Cannabis LLC

In order to provide services to you this Company may need to obtain information from or share information with other individuals, Companies, or providers. This Company needs information to provide you services. If this Company does not get requested information, or if we can not share with others who work with you, then this Company might not be able to provide you services you may need or this Company's assistance my be hindered. Also, this Company may not be following government laws or regulations.

I, (type name of patient or legal representative) authorize YourTime Psychiatry and Medical Cannabis LLC

Indicate the types of records that will be released : [i.e., bank statements, health diagnosis, medical records, personal information]

For the purpose of: [scheduling, billing, etc]

Primary care collaboration and updates

I know that state and federal privacy laws protect my records. I know:

Why I am being asked to release this information.

I do not have to consent to the release of this information. But not doing so may affect this Company's ability to provide needed services to me.

If I do not consent, the information will not be released unless the law otherwise allows it.

I may stop this consent with a written notice at any time, but this written notice will not affect information this Company has already released.

The person(s) or agency (ies) who get my information may be able to pass it on to others.

If my information is passed on to others by this Company, it may no longer be protected by this authorization.

This consent will remain in effect for one year from the date signed or until the purpose of the disclosure is fulfilled, whichever occurs first, unless revoked by the patient or required by law to remain in effect for a longer peroid.