The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment, and when appropriate, coordinate treatment services. This authorization for release of information is made with informed consent, and this consent is subject to revocation by written instructions of the undersigned at any time by sending notification to Valley Medical and Wellness in writing. However, the revocation will not apply to records/information already released/shared. I understand that the information can be re-disclosed by the third party listed above and once received it may no longer be protected by federal or state privacy laws. I understand that my treatment with Valley Medical and Wellness is not conditional upon whether I sign this authorization. I am also aware that some requests for medical records may be charged a fee as allowed by law.