Recipient TitleRecipient Name
Recipient AddressRecipient CityRecipient State
Recipient Zip CodeRecipient TelephoneRecipient FaxRecipient E-Mail

The type and amount of information to be used or disclosed is as follows:

Attendance
Diagnosis
Treatment Plan
Prognosis

Other

Expiration Date of this Autorization:

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke the authorization, I must do so in writing and present my written revocation to the individual in charge of my treatment. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

I understand that authorizing the disclosure of this health information is voluntary. I need not sign this form in order to ensure treatment. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by confidentiality rules.

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