Tyler Smith

 
 Tyler Smith DOB: 90-01-30 (45 yo M) Acc No. 44803 Doc Name: 20-11-06 NP Forms 
 I do 00 /do not 
 authorize the release of information pertaining to HIV/AIDS 
 Purpose of the Requested Disclosure 
 I am authorizing the release of my Protected Health Information for the following purposes: 
 Medical Care 
 Insurance 
 At the request of patient 
 Other (specify) 
 Request by Attorney 
 Time Period for this Authorization 
 This Authorization will expire five  years from the date of its execution. 
 Revocation of This Authorization 
 | understand that I have the right to revoke this Authorization at any time to prohibit future release 
 of my information. To revoke this Authorization, 1 must send written notice to LA Health 
 Solutions, to the attention of LA Health Solutions Medical Records Division at the address 
 indicated above. I understand that my revocation of this Authorization applies to future disclosures 
 only and will not have any effect on any disclosures of Protected Health Information made before 
 receiving the revocation. 
 Redisclosure 
 I understand that my Protected Health Information disclosed pursuant to this Authorization may 
 be redisclosed by the recipient identified above and may no longer be protected from disclosure to 
 others by federal or state law. 
 Waiver 
 I hereby expressly waive any claim of privilege or privacy with respect to the released information. 
 1 release and forever discharge LA Health Solutions and its agents, servants, or employees from 
 all liability or claims, of any kind or character, in any way arising out of the disclosure of the 
 requested information, including disclosures made in good faith. 
 Voluntary 
 1 understand that signing this authorization is voluntary. My treatment, payment, enrollment in a 
 health plan, or eligibility for benefits will not be conditioned upon my authorization of this 
 disclosure. 
 Signature of Patient/Patient's Representative: 
 Date: 
 Jabbith 
 14-09-04 
 Printed Name of Patient's Representative: 
 Relationship to Patient: 
 Tyler Smith DOB: 90-01-30 (45 yo M) Acc No. 44803 Doc Name: 20-11-06 NP Forms 
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