I authorize Ansari HealthShare, NC. to use or disclose all my Health Information

Expiration, Revocation of Authorization and Redisclosure I understand that this authorization can be revoked at any time, except that action has been taken already in reliance on this authorization. Unless otherwise revoked, this authorization has no expiration date. When my health information is released pursuant to a valid authorization, the information may be subject to re-disclosure by recipient and may no longer be protected by federal privacy regulations.

FEE FOR RECORDS Federal and state laws allow a fee to be charged for copying patient records and I will be responsible for payments of such fees unless the records are sent directly to a physician or health facility.

RELEASE AND WAIVER I understand that my medical records may also have information on treatment/diagnosis related to psychiatric or psychological conditions, chemical dependency/alcohol abuse, communicable or infectious disease (ex. HIV, AIDS, ARC,TB and Hepatitis).I hereby waive any privilege concerning such information for the purpose(s) of releasing it to the party or parties authorized above. I also release Ansari HealthShare, Inc. from each of their offices, and their officers, trustees’ agents, and employees from all and any liabilities, damages and claims which may arise from the release of the health information authorized by me above. In cases where someone other than the patient executes the authorization, I understand documentation may be required to support the disclosure of personal health information as required by state and federal law. Records are typically processed in 7 days. Please note that federal and state law allows healthcare providers 30 days to respond to a written request for records.