Include any federal and state protected information under Florida statue 394.d59(9) psychiatric information, Florida statute 397.053 and Florida statute 396.112, drug and/or alcohol abuse information and Florida statute 38160999 (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 expect copy of this information to used, disclosed, as provided in CPR 164.524. Understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions 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 here-by release Brevard Health Center and its employees from any and all liability that may arise from the release of this protected health information as I have directed.