By signing this form, I give my permission Practice to send and receive my health information for the following treatment purposes:
Revocation: You may revoke your authorization to disclosure information by notifying Practice of such revocation in writing. Revocation will not affect any disclosures already made prior to Notice of revocation to Practice.
Expiration: Your authorization is valid for one (1) year
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 information will be encrypted.