The purpose of this release is for medical treatment. This authorization will expire one year from the date it is signed. I understand that: 1) I have the right to revoke this authorization in writing, but if I do, it will not have any effect on actions taken prior to the date that written revocation is received; 2) signing this authorization is voluntary; 3) the information used or disclosed to someone who is not a health care provider or a health plan may no longer be protected by federal privacy regulations and may be forwarded by that party without your consent; 4) I am aware and authorize records disclosed containing sensitive information including use or treatment with: alcohol/drug abuse, mental health, genetics, AIDS/HIV; 5) I may have a copy of the
information disclosed.

PATIENT INFORMATION