Release of Authorization Form

Please correct the errors described below.

All information regarding alcohol and/or Drug abuse or behavioral health will be released unless you restrict by initialing below

Do not release records from alcohol and/or drug abuse or behavioral health information.

I authorize the use and disclosure of my individually identifiable health information as described above, including verbal and written exchanges about the information unless I indicated otherwise. I understand that this authorization is voluntary. I understand that if the person or organization I authorize to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and could be re-disclosed. I understand that my health care and payment for my health care will not be affected if I do not sign this form.

(specify date or event) or, if no date or event is specified, 12 months from the date of signing. A photocopy or fax of this authorization will be treated in the same manner as the original

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your message will be encrypted.