Release of PHI Authorization "*" indicates required fields By signing below I authorize Well Life to use and/or disclose the following Protected Health Information (PHI):Check all that apply* Complete Medical Record for all services to include: History and Physical Exam; Progress Notes; Laboratory Tests, Physician Orders, X-ray Reports, Inpatient Admissions, Physical Therapy. HIV Test Results STD Test Results Records only related to the following date(s) of service Explain:* This information may be used and/or disclosed for the purpose of:Check all that apply* Personal Use Other Describe*If applicable, I authorize Well Life to disclose this to: This authorization expires? (End of day)* MM slash DD slash YYYY I understand that once the information is released it may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations. I understand that I may revoke this authorization at any time by notifying us in writing. However, a revocation will not affect any actions taken by Well Life prior to the receipt of the revocation. I understand that I may refuse to sign this authorization. Patient Name* First Last Patient Consent*Is the patient a minor, unable to give consent and represented by a third party? Yes No Patient Signature* Reset signature Signature locked. Reset to sign again Name of Representative* First Last Relationship to Patient* Signature of Representative* Reset signature Signature locked. Reset to sign again Email*We only require your email in order to send you a copy of this form for your records. We recommend you bring a copy with you on your first visit. Enter Email Confirm Email PhoneThis field is for validation purposes and should be left unchanged.