My complete health record (including but not limited to diagnoses, lab tests, prognosis, treatment, and billing, for all conditions) is to be disclosed upon the request of the person(s) named above unless amended or revoked by myself.
Form of Disclosure (unless another format is mutually agreed upon between my provider and designee):
An electronic record, access through an online portal, a hard copy, or verbal communication.
This authorization shall be effective until all past, present, and future periods unless I revoke it. (NOTE: You may revoke this authorization in writing at any time by notifying your health care providers, preferably in writing.)