Authorization to disclose protected health information Patient's Name First Last Patient's Date of Birth MM slash DD slash YYYY I authorize Central Vermont Home Health & Hospice to disclose the following information:Additional information to be disclosed (check all that apply): Drug and Alcohol Information Psychotherapy Notes Genetic Test Results Mental Health Treatment Information AIDS/HIV Diagnosis/Treatment Information Date range of information to be disclosed (start): MM slash DD slash YYYY Date range of information to be disclosed (end): MM slash DD slash YYYY Disclose the information to: (name and contact information of the recipient) Add Remove*Click on the plus icon to the right of the field to add another recipient.Purpose of this disclosure:Authorization expiration date: (if no date specified, will expire one year from date signed) MM slash DD slash YYYY Please consent to the following:Consent Item 1 I understand that this authorization may be revoked at any time by writing to the Privacy Officer at the address above (although revocation will not be effective if the information has already been disclosed or other actions taken in reliance of the authorization I signed).Consent Item 2 I understand the information used to shared by this authorization could also be shared with others and thereformay not be protected by federal or state confidentiality laws.Consent Item 3 I understand that the refusing to sign this authorization will not have any impact on the care I receive from CVHHH.Consent Item 4 I understand that there are charges for providing copies of my record and that these charges will be explained to me.Printed NameDate MM slash DD slash YYYY SignatureAuthority of Representative, if applicable. Please be prepared to provide identification and proof of appointment.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.