Individual Authorization For Use Or Disclosure of Protected Health Information

I hereby authorize University Medical Group to release or disclose information from the health records of:

covering the period(s) of health care from to the following
Complete Medical Record(s)
Pathology
Discharge Summary
Laboratory Tests
History & Physical Exam
Consultation Reports
Orders and Progress Notes
Operative Report
X-ray Reports
Inspect Records
Other (specify)

You have a right to revoke this authorization by doing so in writing and mailing it to the address above.

Such revocation will be effective to the extent that action has not been taken in reliance on the authorization or, if the authorization was obtained as a condition of obtaining insurance coverage, only to the extent that other law provides the insurer with the right to contest a claim under the policy.

The information used or disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by the regulations that protect individually identifiable health information from use disclosure by health care providers.

This authorization expires in 90 days.