Authorization for Disclosure of PHI

This authorization expires 180 days from the date signed below and covers only treatment(s) for the dates specified above.
I, the undersigned, have read the above and authorized the disclosure such information as herein contained. I have the right to revoke this authorization in writing at any time except to the extent that action has been taken in the reliance upon it. I understand that when this information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless the above named facility from all liability and damages resulting from the lawful release of my Protected Health Information.