Authorization to Release Patient Health Information

I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually transmitted diseases, drugs and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific authorization for these records to be released.

I understand that authorizing this disclosure of patient health information is voluntary. I understand that I do not need to sign this form in order to assure treatment or payment. I understand that unless expressly limited by me in writing, I am specifically authorizing the release of any sensitive medical information that may appear in my medical record including records mental health treatment including pain management, sexually transmitted diseases; AIDS/HIV treatment; and substance abuse. I understand once the information has been released according to the terms of this authorization, the information cannot be recalled. Any disclosure of information carries with it the potential for further release or distribution by the recipient that may not be protected by confidentiality laws. This authorization will expire 90 days from date signed below unless an extension is authorized.