By signing below, I authorize the provider listed to release the records I selected to Crystal Fink CPM, LM and Breath of Life Midwifery LLC.
Extent of Authorization
A. I authorize the release of my health records that relate to mental healthcare, communicable disease, HIV/AIDS status, and/or treatment of alcohol or drug abuse.
B. This medical information my be used by Crystal Fink CPM, LM and Breath of Life MIdwifery for medical treatment or consultation, billing, or other purposes as I may direct.
C. This authorization shall be in force and effect for 12 calendar months from the date of signature.
D. I understand that I have the right to revoke this authorization, in writing, at any time.
E. I understand that my treatment will not be conditioned on whether I sign this authorization.