General Release of Medical Information

I, the undersigned, authorize the release of my medical information as described above. I understand that:

1. Voluntary Disclosure: I am voluntarily authorizing the disclosure of my medical information. I understand that I am not required to sign this form, and my treatment, payment, or eligibility for benefits will not be affected if I choose not to sign.

2. Revocation: I understand that I have the right to revoke this authorization at any time by submitting a written revocation request to the healthcare provider, except to the extent that action has already been taken in reliance on this authorization.

3. Risk of Disclosure: I understand that once my medical information is disclosed, it may be re-disclosed by the recipient and may no longer be protected by HIPAA regulations.

4. Expiration: This authorization will expire on [Date] or upon the following event (if applicable):

Date/Event authorization will expire: (Please Specify)