Medical Release





    	

Authorization to Release Healthcare Information

I request and authorize Upper Valley Behavioral Health Corp. to release healthcare information of the patient named above to:

I understand the following:
I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.

I understand that if the person or entity that receives the described records/information is not subject to federal privacy regulations or other laws, the records/information may be re-disclosed and no longer protected by those regulations.

I understand that the healthcare provider may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization. I may refuse to sign this authorization

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Date: 06/27/2022

Exp Date (One year from date of request): 06/27/2023

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