AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION AUTHORIZATION TO PHYSICIANS, HOSPITALS OR OTHER INSTITUTIONS LD 2g Asby this retease, oF « photocopy of it 10 Uhereby authorize £ inne vuet Oo furnish the Nevada Affletic Commission with copies of any and all ot my medical records, bespital ecards. or ‘other information that it may request regarding conditions for which T have heen under your observation esis, oF prognosis. [also authorize you to send those resus to treatment inch the Nevada Athletic Commission via facsimile to 702-486.2°77, upon the Commission's ies. The purpose of this release is for coniaued patient eare and evaluation You are further autezized, should it be requested, to give the Nevada Athletic Commission an oral report, by telephonic communication, as to my medical condition, care, or teatment. This authorization shall remain effective for one year from the date signed, and is intended to relate to all records predating said execution, and (2) understand that onee the {acknowledge that (1) 1 have he right to revoke the authorization at any time, information is disclosed hereurder, it may no longer be protected by federal privacy lav. understand that | may revoke this authorization only in writing Sent to you by certified mail, The revocation will be effective only upon receipt, except to the extent you have acted in reliance onthe authorization {understand that your treatmext i not conditioned on my signing this authorization, although exceptions will be ‘made for treatment the purpose of which is creating protected! health information to a tht party | ovterstond that refusal to sion this authorization will have no effet on my enroflment, eligibility for benefits, or the amount a third party payors poss forthe health services Ieceive, | understand that the person or entity that receives this information may not be covered by the feletal privacy regulations. in which case the information above may be sedisclosed and no longer protected by these regulations 1 also understand that the person I am authorizing t» use andor disclose the information may receive ‘compensation forthe use andar disclosure, Thave a right to receive a eopy of this authorization. 1 may inspect or obtain « copy of the protected health ‘uformation that {am being asked to use or diselose ou to release documentation which may include highly confidential | | By Signing my name below [am authorizi health information velative to my mesleal stats inthe flowin nee Drugs Ms | Signatur Barfent ignature of categories: HIV/AIDS, Mental Health, Sexually |