The information requested or authorized for release or exchange pertains to:
a. Mental Health
c. HIV/Transmitted disease
d. Drug or alcohol abuse
This authorization is valid for 90 days from the date below. I may cancel this authorization by signing, dating and writing “CANCEL” on this original form or by sending a written, signed and dated request to the doctor above indicating my desire to cancel. I understand that once my information has been released, the recipient might re-disclose it; my doctor has no control over it and privacy laws may no longer protect it. The purpose of this authorization is to improve the quality of my health evaluation and/or treatment.