I hereby authorize Aspire Wellness Center, Inc. to use or disclose my protected health information as indicated below to:
**Please select each line of requested contact for information to be released**
**Please note that no substance abuse information may be released via electronic communication**
**Purpose for Release of Information**
I understand that my express consent is required to release any health care information relating to testing, diagnosis and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health or drug/alcohol treatment or use.
The requested records or information is about health care provided and is valid for one year from the start (date of signature) of this release or 90 days following discharge from this facility.