Reference: _________

This Authorization is made and executed by _________ (date of birth _________), residing at _________, contactable at _________ , hereinafter referred to as the "Patient."

1. Parties to This Authorization

The Patient hereby authorizes _________, located at _________ (the "Disclosing Party"), to disclose the protected health information described in Clause 3 below to _________ of _________ (the "Recipient").

2. Purpose of Disclosure

This disclosure is authorized for the following purpose: _________.

3. Information to Be Disclosed

The Disclosing Party is authorized to release the following categories of records: _________, covering the period from _________ to _________.

4. Expiration

Unless revoked earlier in writing, this Authorization shall remain in effect and expire _________.

5. Right to Revoke

The Patient understands and acknowledges that this Authorization may be revoked at any time by delivering written notice to the Disclosing Party, except to the extent the Disclosing Party has already taken action in reliance on it.

6. Non-Conditioning of Treatment

The Patient acknowledges that treatment, payment, enrollment, or eligibility for benefits has not been, and will not be, conditioned on whether this Authorization is signed.

7. Redisclosure Notice

Information disclosed under this Authorization may be subject to redisclosure by the Recipient and, once disclosed, may no longer be protected by federal privacy regulations.

8. Electronic Signature Consent (E-SIGN Act Compliance)

By completing and electronically submitting this Authorization, the Patient or Representative consents to execute this document using an electronic signature pursuant to the Federal Electronic Signatures in Global and National Commerce Act (E-SIGN Act, 15 U.S.C. §7001 et seq.) and applicable state Electronic Transactions Acts (UETA). The electronic signature holds the same legal validity, binding force, and enforceability as a handwritten ink signature.

	Date Executed
Printed Name: _________ Signer Role: Patient	Date: _________