Release of Information

Please use this section only if you would like Alternative Pride Wellness to communicate with outside providers or organizations regarding your care.

Person or Organization with Whom Information can be Shared

Duration and Revocation of Authorization

This authorization is good for a period of 1 year.

• I understand that I can revoke this authorization at any time prior to that date by contacting the practice in writing.

• I understand that if the practice has already shared the information authorized here at the time I revoke this authorization, then it is too late to prevent that information from being shared.

• I understand that the practice cannot make completion of this authorization a condition for any treatments or benefits I am entitled to, unless this authorization is necessary to determine eligibility for treatment or benefits or to pay for treatments I receive.

Authorization

I hereby authorize Alternative Pride Wellness to release information as described above to, and request information from, the person or organization identified herein. I understand that the person or organization named above may not be subject to the same privacy laws and regulations as Alternative Pride Wellness and may be able to further share the information disclosed under this authorization. I consent to use electronic signatures, and my signature below is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.