By signing this authorization form, I understand that:
     • My health information may be shared electronically.
     • I understand that I have the right to request restrictions as to how my protected health information maybe used or disclosed to carry out treatment, payment or health care operations, or other disclosures.
     • The sharing of my health information will follow state and federal laws and regulations.
     • I understand that the information in my health record may include information related to sexually
transmitted disease, acquired or mental health services, and treatment of alcohol or drug abuse.
     • I can withdraw my consent at any time; however, the revocation will not apply to information that has
already been released in response to this authorization.
     • Any disclosure of information carries with it the potential for unauthorized re-disclosure, and the
information may not be protected by federal confidentiality rules.

     • This authorization of release of information will expire on (enter date below)or one year after the date
signed if not specified.