As required by the Health Information Portability Act of 1996 (HIPAA) and California law, this practice may not use or disclose your individually identifiable health information except as provided in our Notice of Privacy Practices without your authorization. Your completion of this form means that you are giving permission for the uses and disclosure described below. Please review and complete this form carefully. It may be invalid if not fully completed. You may want to ask the person or entity you want to receive your information to complete the sections detailing the information to be released and purpose of the disclosure.