I authorize the following organization to release all health care information as stated below to the organization listed:
Information to be released from:
1240 Hwy 54W Suite 100
Fayetteville, GA 30214
Fax (770) 461-5041
Information to be released to:
Continued Medical Care
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
I understand this authorization will expire in 90 days after the date below and covers only treatment prior to that date. I understand that I may revoke in writing this authorization at any time. I understand that the information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer be protected by federal privacy law. I acknowledge that a revocation will not affect actions already taken in reliance on the authorization form. I also consent to the release of medical information which may contain treatment for physical and/or emotional illness, communicable disease, alcohol or drug abuse treatment, and/or HIV, AIDS, or AIDS related information. I understand this authorization will expire in 90 days after the date below and it covers only treatment prior to that date. I also understand that I may revoke in writing this authorization at any time.
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