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Authorization for Release of Protected Health Information

I hereby authorize the following physician to release/disclose my Protected Health Information to Brevard Health Center PL (Gobi Venkata Balaji, MD):
Information authorized to release for service rendered during the period from
to
to include any Federal and State protected information under Florida Statute 394.459(9) psychiatric information, Florida Statute 397.053 and Florida Statute 396.112, Drug and/or Alcohol Abuse information and Florida Statute 381.60999 (2) Human Immunodeficiency Virus test results (AIDS and related conditions).
I understand that authorizing the disclosure of this protected health information is voluntary. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. 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 any doubts about disclosure of protected health information, I may contact Brevard Health Center.
I understand and direct that this authorization remains in effect for 6 months or until I revoke it in writing. I herby release Brevard Health Center, PL and its employees from any and all liability that may arise from the release of this protected health information as I directed.

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