This information has been disclosed to you from records protected by Federal confidentiality rules. The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. The Federal rules restrict use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

First Name *

Last Name *

Email address *

Mobile phone number *

Date of Birth

Authorization: I authorize the healthcare provider named below to use and disclose the protected health information described below to medical staff at PMC *(healthcare provider's name)

Effective Period: This authorization for release of information covers the period of healthcare from: (please check a. OR b.)

From

b. all past, present, and future periods.

Extent of Authorization: I authorize the release of my complete health record, including mental health records and treatment of alcohol or drug abuse, with the exception of the following information: *Please specify

This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. *

I understand that my payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

Signature *

Date *

Printed Name

Please review to ensure the details are correct before completion.