Purpose of the Disclosure: At the request of the individual.
Disclosed Records, Information, and Data May not be Protected: When my
information is sued to disclose pursuant to this release, it may he subject to re-disclosure by the
recipient and may no longer be protected by the Federal. H.LP.A.A. privacy rule,
Conditioning of Treatment: The provider will not condition treatment,
payment, enrollment in, a health plan or eligibility for benefits (if applicable) on whether I
provider authorization for the requested use or disclosure.
Intention to Comply with Federal Law: This authorization is intended to
comply with all applicable federal and state laws including the H.LP.A.A.
Personal Representative's Signature (if applicable)
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