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:*Patient name:*Date of Birth* 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). I authorize the release of my complete health records except: Mental health records Communicable diseases (including HIV and AIDS) Alcohol/drug abuse treatment Purpose of Authorization: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 or legally authorized individual signature:Date Signed:* Name if signed on behalf of the patient :Relationship (parent, legal guardian, personal representative, etc.