Authorization to Disclose Health Information

1. I authorize ______________________________________________ to disclose the above named individual's health information as described below to Dr. Bryan King, Tuscaloosa Orthopedic & Joint Institute, LLC, 100 Rice Mine Road Loop, STE 205, Tuscaloosa, AL 35406 or by fax to: (205)354-2679.

2. The type and amount of information to be used or disclosed is as follows: (include dates where appropriate)

3. I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

4. This information may be disclosed at the request of the individual.

5. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to Neal Griffin, Privacy/Security Officer. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. If I fail to specify an expiration date, event or condition, this authorization will expire in six months.

6. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CRF 164.524 of the Federal Register Rules and Regulations. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure or my health information, I can contact Tina Johnson, Privacy/Security Officer.