­­­­­­­­­Authorization to Use/Disclose Information

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.

  • I understand that I may revoke this authorization at any time by notifying Amberleigh Yoegel, LCPC/Director of Compliance and Quality Assurance, in writing, and this authorization wil
  • I understand that Aspire Wellness Center, Inc. may not condition treatment, payment, enrollment or eligibility for benefits on my signing this authorization, unless my treatment is related to research and the purpose of this authorization is to enable the protected health information described above to be used for such research.
  • I understand that information disclosed based on this authorization may be subject to re-disclosure by the recipient, and no longer protected by federal privacy regulations.
  • I understand that I may request a copy of this form after I sign it.
Electronically acknowledged by the name indicated above, on:

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.

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