* I consent to disclose the above marked specialized information

***NOTE: If this section is not completed, then records of this type, if they exist for this patient, will not be released.

ACKNOWLEDGMENTS AND AUTHORIZATION SIGNATURE

By signing this Authorization, I acknowledge that I have read this Authorization form and understand that:

• I may refuse to authorize the disclosure of some or all of the above health information but that my refusal may result in improper diagnosis or treatment, denial of coverage or claims for health insurance benefits or other insurance, or other adverse consequences.
• I may revoke this authorization at any time, either orally or in writing, by notifying GVH in the manner described in GVH’s Notice of Privacy Practices, except to the extent that GVH or any other person has already acted in reliance on it. I understand that my revocation may be the basis for the denial of health or other insurance coverage or benefits.
• There is the potential that information disclosed pursuant to this Authorization may be redisclosed by the recipient(s) of the information and that, as a result, the information may no longer be protected.
• Incomplete forms cannot be processed.
• The disclosing entity may charge a fee for copying the requested records.
• A copy, fax or scan of this Authorization will be considered as valid as the original.
• I have the right to receive a copy of this signed authorization.

PLEASE ALLOW 10 BUSINESS DAYS TO FULFILL RECORDS REQUESTS.

* Signature by an authorized representative certifies such person has the legal authority to authorize the disclosure on behalf of the patient.