1. I authorize the use or disclosure of the above-named individual's health information as described below.

2. The following individual or organizations are authorized to make the disclosure:

3. The type and amount of information to be used or disclosed is as follows: Problem list, Physical Therapist notes, Nurses notes, Doctors notes, Medication list, list of allergies, Immunization record, most recent history and physical, most recent discharge summary, laboratory results, x-ray and/or imaging reports, consultation reports, entire records and

4. I understand that the information in my health record may Include information relating to sexually transmitted disease(s), Human immunodeficiency virus (HIV) and/or acquired immu- nodeficiency syndrome (AIDS It may also include information

about behavioral or mental health services and treatment for

5. This information may be disclosed to, and be used by, the following individuals(s) or organization(s

a2z Physical Therapy, LLC located in the state of Maryland FAX: 883-287-7171 IPHONE:410-929-9010

6. This information is being disclosed for the following purpose (s): For the preparation of a personal injury case, by providing medical records from a2z physical therapy and additional healthcare providers.

8. Unless otherwise revoked, this authorization will expire on the following date, event or condition: Upon the conclusion of my physical therapy.

9. I understand that once the information is disclosed

7. I understand that I have the right to revoke this authorization at any time. I understand that in order to revoke this authoriza- federal privacy regulations. tion, I must do so in writing and present my written revocation to ,I understand that this

pursuant to this authorization, it may be re-disclosed by the recipient and the information may not be protected by

revocation will not apply to my insurance company when the law provided my insurer with the right to contest a claim under my policy.

10. I understand that I need not sign this form in order to ensure health care treatment, payment or enrollment in my health plan or eligibility for benefits.