Please choose from Option 1 OR Option 2
The following individuals have permission to interact with Five Rivers Health Centers on my behalf, (check each box that applies).
I understand that this authorization shall remain in effect for one year from the date of my signature below unless I specify an earlier expiration date in this space
I understand also, that except to the extent that action has been taken based on my authorization, I may withdraw this authorization at any time by written notification to the parties involved (see Notice of Privacy Practices).