(Healthcare facility/physician)
to release the protected health information (PHI) described below. Unless specifically excluded, the PHI may include
information about: alcohol and drug abuse treatment, behavioral or mental health services and/or communicable
diseases and infections, such as sexually transmitted diseases, AIDS and HIV.
AUTHORIZATION:
I understand that unless revoked, this authorization is valid for 90 days from the date of signing. I may revoke this authorization in writing at any time except to the extent disclosure has already been made in accordance with this document. Once health care information is disclosed, the person or organization that receives it, may re-disclose it, and that it may no longer be protected by privacy laws.