Fuller Living Authorization for Release of Information

Please correct the errors described below.
(your first and last name)

hereby voluntarily authorize the disclosure of information from my health record.

(Name of Facility)
(name of person/organization/facility)


I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.


Unless sooner revoked, this authorization expires 6 months from the date of this authorization.


I further understand that this entity will not condition my treatment on whether I give authorization for the requested disclosure.

Form of Disclosure:


I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization may be redisclosed by the recipiet and the protected health information will no longer be protected by the HIPAA privacy regulations, unless a State law applies that is more strict than HIPAA and provides additional privacy protection.

Your information will be encrypted.