Authorization for Use and Disclosure of Protected Health Information

under HIPAA RULE 164.508

Please correct the errors described below.

You May Refuse to Sign This Authorization

I specifically authorize you to use and disclose the following types of super-confidential information (initial where appropriate):

HIV records (including HIV test results) and sexually transmissible diseases

Alcohol and substance abuse diagnosis and treatment records

Psychotherapy records

Tuberculosis

All hospital records

All of the above

I specifically authorize you to use and disclose the following Protected Health Information. Please initial one or more of the following, if applicable:

Written Medical Records

X-rays/MRI/CT

Billing records

Prescription records

Your information will be encrypted.

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