AUTHORIZATION FOR THE USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION AUTHORIZATION FOR THE USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION Authorization: I authorize Colorado Clinic to obtain my protected health information from:Name of individual or organization:*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Fax:Scope of Authorization:* I authorize the release of my complete health records (including records relating to mental healthcare, communicable diseases, HIV or Aids, and treatment of alcohol or drug abuse). OR I authorize the release of my complete health records except: Mental health records Communicable diseases (including HIV and AIDS) Alcohol/drug abuse treatment This Authorization Ends:On this dateWhen the following occursDate When the following occurs:Purpose of Authorization*Workers' Compensation ClaimPersonal Injury ClaimOtherPlease specify:Rights This authorization is voluntary. I understand I do not have to sign this authorization in order to get health care benefits. I may revoke this authorization in writing at any time. If I do, it will not affect any actions already taken based upon this authorization. I am entitled to a copy of this authorization. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.Patient name:*Date of Birth* Patient or legally authorized individual signature:Date Signed:* Name if signed on behalf of the patient :Relationship (parent, legal guardian, personal representative, etc.