In accordance with applicable state and federal law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") (42 U.S.C. § 1320d et seq.), I understand that:

1. This document may authorize disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV-RELATED INFORMATION. In the event the health information described in Item 3 includes any of these types of information, and I do not check the boxes to include such information, I specifically authorize release of such information to the person(s) indicated in Item 1.
2. I have a right to receive copies of my mental health records unless (i) such access would endanger my or another individual's life or physical safety, or (ii) the health record makes reference to a person other than a health care provider and the access requested would be reasonably likely to cause substantial harm to such referenced person, in which case records may be sent to the physician/psychologist of my choice.
3. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
4. Information disclosed under this authorization might be redisclosed by the recipient and this redisclosure may no longer be protected to the same extent as such health information was protected by law while solely in the possession of Vita Bella Medical Group, P.A. of Florida. If I am authorizing the release of HIV-related, alcohol, or drug treatment, or mental health treatment information, the recipient is prohibited from re-disclosing such information without my authorization unless permitted to do so under federal or state law. Also, according to state law, no person to whom health records are disclosed shall redisclose or otherwise reveal the health records of an individual, beyond the purpose for which such disclosure was made, without first obtaining the individual's specific authorization to such redisclosure. This redisclosure prohibition shall not, however, prevent any health care entity that receives health records from another health care entity from making subsequent disclosures as permitted under this section and the United States Department of Health and Human Services (HHS) regulations relating to privacy of the electronic transmission of data and protected health information promulgated by HHS as required by HIPAA.
5. I understand that I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so via email or in writing, and present my revocation in the following manner:
   
   Via e-mail: privacy@vitabella.com
   
   Via mail: Vita Bella Medical Group, P.A. of Florida
   11201 North Tatum Blvd, Suite 300
   Phoenix, AZ 85208
   
   I understand that this revocation will not apply to information that has already been released in response to this authorization. Unless otherwise revoked, this authorization will expire upon the date or event described in Item 4 above. If I have not specified a date or event, this authorization will expire two (2) years from the date signed.
6. All items on this form have been completed and my questions about this form have been answered.  In addition, I have been provided a copy of the form.

Note: If other than the patient's signature, a copy of legal paperwork verifying the patient's personal representative MUST accompany the request (e.g., court appointed guardian, durable power of attorney for health care). Exception: parent signing for a patient under the age of eighteen.