1. I hereby authorize to use and/or disclose the protected health information described below to .
2. Authorization for Release of Information. Covering the period of health care from to OR
   
   

   all past, present and future periods
   • Items or services not furnished under arrangements by the skilled nursing facility.

   OR

   • I hereby authorize the release of my complete health record
     Mental health records
     Communicable diseases (including HIV and AIDS)
     Alcohol/drug abuse treatment
     Other (please specify):
3. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
4. This authorization shall be in force and effect until , at which time this authorization expires.
5. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
6. I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization.
7. 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.

Version: 687955.03