CONSENT TO RELEASE MEDICAL INFORMATION

This authorizes the listed provider or facility to release the following medical information and/or documentation to Vortex Psychiatry in accordance with the Lanterman-Petris-Short Act and/or 42 Code of Federal Regulation.

I understand that my protected health information may be used for treatment, payment, or healthcare operations. I understand I have the right to review the privacy notice prior to signing this consent and Vortex Psychiatry has reserved the right to change their privacy practice, if applicable. I understand that I have the right to request a restriction on the use of protected health information. When Vortex Psychiatry agrees to the request, the request is binding on Vortex Psychiatry. This consent expires in one year unless I notify Vortex Psychiatry otherwise in writing. I understand that I have the right to revoke this consent in writing except to the extent that action has been taken in reliance on this consent. I understand that information used or disclosed pursuant to this consent may be subject to re-disclosure by the recipient and no longer be protected by rule 45 CFR 164.5060 & 508; 65 Red. Reg.at 82509.I further release my attending or primary care physician and his/her/their associates, employees and agents from any liability arising from the release of this information or record to such designated person or agencies. I have carefully read, and I understand the foregoing. I consent to the release of the above-specified information about myself and the treatment or services he/she/they or myself have received to: Vortex Psychiatry Inc. 4155 Blackhawk Plaza Circle, Suite 240, Danville, CA 94506