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<head>਀㰀洀攀琀愀 栀琀琀瀀ⴀ攀焀甀椀瘀㴀䌀漀渀琀攀渀琀ⴀ吀礀瀀攀 挀漀渀琀攀渀琀㴀∀琀攀砀琀⼀栀琀洀氀㬀 挀栀愀爀猀攀琀㴀眀椀渀搀漀眀猀ⴀ㄀㈀㔀㈀∀㸀 
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<A NAME="TOP"></A> ਀㰀戀漀搀礀 戀最挀漀氀漀爀㴀∀⌀䘀䘀䘀䘀䘀䘀∀ 戀愀挀欀最爀漀甀渀搀㴀∀⸀⸀⼀椀洀愀最攀⼀戀愀挀欀最爀漀甀渀搀㐀⸀最椀昀∀ 吀䔀堀吀㴀∀⌀㔀䐀㌀㔀㄀㐀∀ 
 LINK="#cc3333" VLINK="#cc3333" >਀ऀ 
	<!----------------header ---------->਀ 㰀琀愀戀氀攀 戀最挀漀氀漀爀㴀∀⌀挀挀昀昀昀昀∀ 眀椀搀琀栀㴀 ∀㄀　　─∀戀漀爀搀攀爀㴀 ∀㌀∀ 挀攀氀氀瀀愀搀搀椀渀最㴀∀㄀∀ 挀攀氀氀猀瀀愀挀椀渀最㴀∀㄀∀ 㸀 
    <tr>਀ 
       ਀        㰀琀搀 愀氀椀最渀㴀∀挀攀渀琀攀爀∀ 眀椀搀琀栀㴀 ∀㄀　─∀ 栀攀椀最栀琀㴀 ∀㄀　∀ 爀漀眀猀瀀愀渀㴀∀㄀∀㸀㰀愀 栀爀攀昀㴀∀⸀⸀⼀椀渀搀攀砀⸀栀琀洀氀∀㸀㰀昀漀渀琀 猀椀稀攀㴀∀㈀∀ 挀漀氀漀爀㴀∀戀氀愀挀欀∀㸀䠀漀洀攀㰀⼀昀漀渀琀㸀㰀⼀愀㸀㰀⼀琀搀㸀 
        ਀         
	    <td align="center" width= "10%" height= "10" rowspan="1"><a href="../text/location.html"><font size="2" color="black">Location</font></a></td>਀ऀ     
	    <td align="center" width= "10%" height= "10"><a href="../text/contact.html"><font size="2" color="black">Contact</font></a></td>਀ऀ     
	    	    <td align="center" width= "10%" height= "10"><a href="../text/privacy.html"><font size="2" color="black">Privacy</font></a></td>਀ऀ    ऀ    ऀ     
	    	    <td align="center" width= "10%" height= "10"><a href="../text/forms.html"><font size="2" color="black">Forms</font></a></td>਀                     
	    	    <td align="center" width= "10%" height= "10"><a href="../text/links.html"><font size="2" color="black">Links</font></a></td>਀ऀ     
	    	    <td align="center" width= "10%" height= "10"><a href="mailto:Dr. Jones <jira@jonesinaudiology.com>"><font size="2" color="black">E-mail</font></a></td>਀ऀ     ऀ 
	 </tr>਀㰀⼀琀愀戀氀攀㸀 
਀㰀戀爀㸀㰀戀爀㸀 
਀ 
<A NAME="TOP"></A> ਀㰀戀漀搀礀 戀最挀漀氀漀爀㴀∀⌀䘀䘀䘀䘀䘀䘀∀ 戀愀挀欀最爀漀甀渀搀㴀∀⸀⸀⼀椀洀愀最攀⼀戀愀挀欀最爀漀甀渀搀㐀⸀最椀昀∀ 吀䔀堀吀㴀∀⌀㔀䐀㌀㔀㄀㐀∀ 
 LINK="#cc3333" VLINK="#cc3333" >਀ 
਀㰀℀℀戀漀搀礀 氀愀渀最㴀䔀一ⴀ唀匀 氀椀渀欀㴀戀氀甀攀 瘀氀椀渀欀㴀瀀甀爀瀀氀攀㸀 
<!---------------- release (form table)---------->਀㰀挀攀渀琀攀爀㸀 
 <table bgcolor="#ffffff" width= "800"border= "1" height= "1000" cellpadding="20" cellspacing="1" >਀  㰀℀ⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀ栀攀愀搀攀爀 攀渀搀 ⴀⴀⴀⴀⴀⴀⴀⴀⴀ㸀 
<!---------------- release (form table)---------->਀㰀挀攀渀琀攀爀㸀 
 <table bgcolor="#ffffff" width= "800"border= "1" height= "1000" cellpadding="20" cellspacing="1" >਀  㰀℀ⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀ 爀攀氀攀愀猀攀 ⠀瀀搀昀⤀ⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀ㸀  
  <tr>਀ 㰀琀搀㸀 
਀ऀ㰀愀 栀爀攀昀㴀∀⸀⸀⼀倀䐀䘀搀漀挀⼀䨀䤀刀䄀 开刀攀氀攀愀猀攀开 ㄀㄀ⴀ㈀㠀ⴀ㈀　㄀㈀⸀瀀搀昀∀㸀䌀氀椀挀欀 栀攀爀攀 琀漀 搀漀眀渀氀漀愀搀 愀 瀀爀椀渀琀攀爀 昀爀椀攀渀搀氀礀 倀䐀䘀 搀漀挀甀洀攀渀琀⸀㰀⼀愀㸀ऀ 
</td>਀ 㰀⼀琀爀㸀 
 <!---------------- release (pdf)end ---------->਀  㰀琀爀㸀 
 <td>਀㰀搀椀瘀 挀氀愀猀猀㴀圀漀爀搀匀攀挀琀椀漀渀㄀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀瀀漀猀椀琀椀漀渀㨀爀攀氀愀琀椀瘀攀㬀稀ⴀ椀渀搀攀砀㨀㄀✀㸀㰀猀瀀愀渀 
style='position:absolute;left:-1px;top:-1px;width:772px;height:136px'><img਀眀椀搀琀栀㴀㜀㜀㈀ 栀攀椀最栀琀㴀㄀㌀㘀 猀爀挀㴀∀⸀⸀⼀椀洀愀最攀⼀䨀䤀刀䄀栀攀愀搀吀⸀最椀昀∀ 愀氀琀㴀∀䨀䤀刀䄀 氀漀最漀 ㈀㘀∀㸀㰀⼀猀瀀愀渀㸀㰀⼀猀瀀愀渀㸀☀渀戀猀瀀㬀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀㸀☀渀戀猀瀀㬀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀㸀☀渀戀猀瀀㬀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀㸀☀渀戀猀瀀㬀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀㸀☀渀戀猀瀀㬀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀㸀☀渀戀猀瀀㬀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀㸀☀渀戀猀瀀㬀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀㸀☀渀戀猀瀀㬀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀㸀☀渀戀猀瀀㬀㰀⼀瀀㸀 
਀㰀⼀搀椀瘀㸀 
਀㰀戀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㈀⸀　瀀琀㬀昀漀渀琀ⴀ昀愀洀椀氀礀㨀∀吀椀洀攀猀 一攀眀 刀漀洀愀渀∀Ⰰ∀猀攀爀椀昀∀㬀 
color:black'><br clear=all style='page-break-before:auto'>਀㰀⼀猀瀀愀渀㸀㰀⼀戀㸀㰀戀爀 挀氀攀愀爀㴀䄀䰀䰀㸀 
਀㰀搀椀瘀 挀氀愀猀猀㴀圀漀爀搀匀攀挀琀椀漀渀㈀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀 愀氀椀最渀㴀挀攀渀琀攀爀 猀琀礀氀攀㴀✀洀愀爀最椀渀ⴀ戀漀琀琀漀洀㨀㌀⸀　瀀琀㬀琀攀砀琀ⴀ愀氀椀最渀㨀挀攀渀琀攀爀✀㸀㰀戀㸀㰀猀瀀愀渀 
style='font-size:12.0pt'>Authorization for Release of Protected Health਀䤀渀昀漀爀洀愀琀椀漀渀㰀⼀猀瀀愀渀㸀㰀⼀戀㸀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀 猀琀礀氀攀㴀✀洀愀爀最椀渀ⴀ戀漀琀琀漀洀㨀㌀⸀　瀀琀㬀琀攀砀琀ⴀ愀氀椀最渀㨀樀甀猀琀椀昀礀✀㸀㰀猀瀀愀渀 
style='font-size:11.0pt'>This form authorizes Jones Institute for਀刀攀栀愀戀椀氀椀琀愀琀椀瘀攀 䄀甀搀椀漀氀漀最礀Ⰰ 䰀䰀䌀 ⠀䨀䤀刀䄀⤀ 琀漀 猀栀愀爀攀 瀀攀爀猀漀渀愀氀 栀攀愀氀琀栀⼀洀攀搀椀挀愀氀 
information that is protected by the Health Insurance Portability and਀䄀挀挀漀甀渀琀愀戀椀氀椀琀礀 䄀挀琀 漀昀 ㄀㤀㤀㘀 ⠀䠀䤀倀䄀䄀⤀⸀㰀⼀猀瀀愀渀㸀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀 猀琀礀氀攀㴀✀洀愀爀最椀渀ⴀ戀漀琀琀漀洀㨀㌀⸀　瀀琀✀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀䤀渀昀漀爀洀愀琀椀漀渀 
about:</span></p>਀ 
<p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:2.0pt;਀洀愀爀最椀渀ⴀ氀攀昀琀㨀⸀㔀椀渀✀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀倀愀琀椀攀渀琀 一愀洀攀㨀ꀀ 㰀甀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀⼀甀㸀㰀⼀猀瀀愀渀㸀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀 猀琀礀氀攀㴀✀洀愀爀最椀渀ⴀ琀漀瀀㨀　椀渀㬀洀愀爀最椀渀ⴀ爀椀最栀琀㨀　椀渀㬀洀愀爀最椀渀ⴀ戀漀琀琀漀洀㨀㈀⸀　瀀琀㬀 
margin-left:.5in'><span style='font-size:11.0pt'>Date of Birth:   <u>                                                                                                                                    </u></span></p>਀ 
<p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:2.0pt;਀洀愀爀最椀渀ⴀ氀攀昀琀㨀⸀㔀椀渀✀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀䄀搀搀爀攀猀猀㨀ꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀甀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀⼀甀㸀㰀⼀猀瀀愀渀㸀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀 猀琀礀氀攀㴀✀洀愀爀最椀渀ⴀ戀漀琀琀漀洀㨀㐀⸀　瀀琀✀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 倀栀漀渀攀㨀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀甀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀⼀甀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 䔀ⴀ洀愀椀氀㨀 㰀甀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀⼀甀㸀㰀⼀猀瀀愀渀㸀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀 猀琀礀氀攀㴀✀洀愀爀最椀渀ⴀ戀漀琀琀漀洀㨀㌀⸀　瀀琀✀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀䴀愀礀 
be shared between JIRA and the following:</span></p>਀ 
<p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:2.0pt;਀洀愀爀最椀渀ⴀ氀攀昀琀㨀⸀㔀椀渀✀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀一愀洀攀㨀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀甀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀⼀甀㸀㰀⼀猀瀀愀渀㸀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀 猀琀礀氀攀㴀✀洀愀爀最椀渀ⴀ琀漀瀀㨀　椀渀㬀洀愀爀最椀渀ⴀ爀椀最栀琀㨀　椀渀㬀洀愀爀最椀渀ⴀ戀漀琀琀漀洀㨀㈀⸀　瀀琀㬀 
margin-left:.5in'><span style='font-size:11.0pt'>Agency:           <u>                                                                                                                                    </u></span></p>਀ 
<p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:2.0pt;਀洀愀爀最椀渀ⴀ氀攀昀琀㨀⸀㔀椀渀✀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀䄀搀搀爀攀猀猀㨀ꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀甀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀⼀甀㸀㰀⼀猀瀀愀渀㸀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀 猀琀礀氀攀㴀✀洀愀爀最椀渀ⴀ琀漀瀀㨀　椀渀㬀洀愀爀最椀渀ⴀ爀椀最栀琀㨀　椀渀㬀洀愀爀最椀渀ⴀ戀漀琀琀漀洀㨀㈀⸀　瀀琀㬀 
margin-left:.5in'><span style='font-size:11.0pt'>Phone:             <u>                                                </u>            Fax:     <u>                                                            </u></span></p>਀ 
<p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:5.0pt;਀洀愀爀最椀渀ⴀ氀攀昀琀㨀⸀㔀椀渀✀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀䔀ⴀ洀愀椀氀㨀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀甀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀⼀甀㸀㰀⼀猀瀀愀渀㸀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀 猀琀礀氀攀㴀✀洀愀爀最椀渀ⴀ戀漀琀琀漀洀㨀㘀⸀　瀀琀㬀琀攀砀琀ⴀ愀氀椀最渀㨀樀甀猀琀椀昀礀✀㸀㰀猀瀀愀渀 
style='font-size:11.0pt'>Specific description of the heath information to be਀猀栀愀爀攀搀 ⠀㰀椀㸀椀渀挀氀甀搀攀 搀愀琀攀猀 漀昀 猀攀爀瘀椀挀攀Ⰰ 愀瀀瀀漀椀渀琀洀攀渀琀 搀愀琀攀猀Ⰰ 琀礀瀀攀 漀昀 猀攀爀瘀椀挀攀Ⰰ 攀琀挀⸀㰀⼀椀㸀⤀㨀 
<u>                                                                                                                                                                           </u></span></p>਀ 
<p class=MsoNormal style='text-align:justify'><span style='font-size:11.0pt'>Information਀洀愀礀 戀攀 猀栀愀爀攀搀 甀猀椀渀最 愀 瘀愀爀椀攀琀礀 漀昀 洀攀琀栀漀搀猀Ⰰ 椀渀挀氀甀搀椀渀最Ⰰ 戀甀琀 渀漀琀 氀椀洀椀琀攀搀 琀漀Ⰰ 戀礀 瀀栀漀渀攀Ⰰ 
in writing, by fax, via computer file, or by email unless otherwise directed or਀爀攀猀琀爀椀挀琀攀搀 戀攀氀漀眀⸀㰀⼀猀瀀愀渀㸀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀 猀琀礀氀攀㴀✀洀愀爀最椀渀ⴀ氀攀昀琀㨀⸀㔀椀渀✀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀开开开开开ꀀ 一漀 
restrictions</span></p>਀ 
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:11.0pt'>_____  Other਀搀椀爀攀挀琀椀漀渀猀⼀爀攀猀琀爀椀挀琀椀漀渀猀㨀 㰀甀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀⼀甀㸀㰀⼀猀瀀愀渀㸀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀 猀琀礀氀攀㴀✀洀愀爀最椀渀ⴀ琀漀瀀㨀㌀⸀　瀀琀✀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀吀栀攀 
purpose of this release is: <u>            </u> Coordination of care for the਀渀愀洀攀搀 瀀愀琀椀攀渀琀⸀㰀⼀猀瀀愀渀㸀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀 猀琀礀氀攀㴀✀洀愀爀最椀渀ⴀ戀漀琀琀漀洀㨀㐀⸀　瀀琀✀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀甀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀⼀甀㸀ꀀ伀琀栀攀爀 
(specify): <u>                                                                                             </u></span></p>਀ 
<p class=MsoNormal style='margin-bottom:2.0pt'><span style='font-size:11.0pt'>My਀猀椀最渀愀琀甀爀攀 戀攀氀漀眀 椀渀搀椀挀愀琀攀猀 䤀 甀渀搀攀爀猀琀愀渀搀 愀渀搀 愀最爀攀攀 琀栀愀琀㨀㰀⼀猀瀀愀渀㸀㰀⼀瀀㸀 
਀㰀甀氀 猀琀礀氀攀㴀✀洀愀爀最椀渀ⴀ琀漀瀀㨀　椀渀✀ 琀礀瀀攀㴀搀椀猀挀㸀 
 <li class=MsoNormal style='text-align:justify'><span style='font-size:11.0pt'>Only਀     椀渀昀漀爀洀愀琀椀漀渀 琀栀愀琀 椀猀 猀瀀攀挀椀昀椀攀搀 愀戀漀瘀攀 愀渀搀 渀攀攀搀攀搀 琀漀 昀甀氀昀椀氀氀 琀栀攀 瀀甀爀瀀漀猀攀⠀猀⤀ 氀椀猀琀攀搀 
     above will be released.</span></li>਀ 㰀氀椀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀 猀琀礀氀攀㴀✀琀攀砀琀ⴀ愀氀椀最渀㨀樀甀猀琀椀昀礀✀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀吀栀椀猀 
     authorization is voluntary. I may refuse to sign this authorization and਀     琀栀攀 瀀愀琀椀攀渀琀✀猀 琀爀攀愀琀洀攀渀琀 愀渀搀⼀漀爀 瀀愀礀洀攀渀琀 漀戀氀椀最愀琀椀漀渀猀 眀椀氀氀 渀漀琀 戀攀 愀昀昀攀挀琀攀搀 
     unless either of the following applies: (a) treatment is related to਀     爀攀猀攀愀爀挀栀 愀渀搀 琀栀攀 猀栀愀爀椀渀最 漀昀 椀渀昀漀爀洀愀琀椀漀渀 椀猀 爀攀氀愀琀攀搀 琀漀 猀甀挀栀 爀攀猀攀愀爀挀栀㬀 漀爀 
     (b) treatment is solely for the purpose of creating protected health਀     椀渀昀漀爀洀愀琀椀漀渀 昀漀爀 搀椀猀挀氀漀猀甀爀攀 琀漀 愀 琀栀椀爀搀ⴀ瀀愀爀琀礀⸀ 㰀⼀猀瀀愀渀㸀㰀⼀氀椀㸀 
 <li class=MsoNormal style='text-align:justify'><span style='font-size:11.0pt'>JIRA਀     眀椀氀氀 渀漀琀 爀攀挀攀椀瘀攀 昀椀渀愀渀挀椀愀氀 漀爀 椀渀ⴀ欀椀渀搀 挀漀洀瀀攀渀猀愀琀椀漀渀 漀爀 爀攀洀甀渀攀爀愀琀椀漀渀 椀渀 攀砀挀栀愀渀最攀 
     for sharing protected health information unless an applicable legal਀     攀砀挀攀瀀琀椀漀渀 愀瀀瀀氀椀攀猀⸀ 㰀⼀猀瀀愀渀㸀㰀⼀氀椀㸀 
 <li class=MsoNormal style='text-align:justify'><span style='font-size:11.0pt'>Health਀     椀渀昀漀爀洀愀琀椀漀渀 猀栀愀爀攀搀 洀愀礀 戀攀 猀甀戀樀攀挀琀 琀漀 爀攀搀椀猀挀氀漀猀甀爀攀 戀礀 琀栀攀 爀攀挀椀瀀椀攀渀琀 漀昀 琀栀攀 
     health information and may no longer be protected by federal or state law.਀     㰀⼀猀瀀愀渀㸀㰀⼀氀椀㸀 
 <li class=MsoNormal style='text-align:justify'><span style='font-size:11.0pt'>Unless਀     漀琀栀攀爀眀椀猀攀 爀攀瘀漀欀攀搀Ⰰ 琀栀椀猀 愀甀琀栀漀爀椀稀愀琀椀漀渀 眀椀氀氀 攀砀瀀椀爀攀 漀渀 开开开开开开开开开开 ⠀搀愀琀攀Ⰰ 
     event, or condition). If I fail to specify a date, event, or condition,਀     琀栀椀猀 愀甀琀栀漀爀椀稀愀琀椀漀渀 眀椀氀氀 攀砀瀀椀爀攀 椀渀 漀渀攀 ⠀㄀⤀ 礀攀愀爀⸀ 㰀⼀猀瀀愀渀㸀㰀⼀氀椀㸀 
 <li class=MsoNormal style='text-align:justify'><span style='font-size:11.0pt'>I਀     洀愀礀 爀攀瘀漀欀攀 琀栀椀猀 愀甀琀栀漀爀椀稀愀琀椀漀渀 愀琀 愀渀礀 琀椀洀攀 戀礀 渀漀琀椀昀礀椀渀最 䨀䤀刀䄀 椀渀 眀爀椀琀椀渀最Ⰰ 
     but, if I do, it will not have any effect on uses or disclosure prior to਀     琀栀攀 爀攀挀攀椀瀀琀 漀昀 琀栀攀 爀攀瘀漀挀愀琀椀漀渀⸀ 㰀⼀猀瀀愀渀㸀㰀⼀氀椀㸀 
 <li class=MsoNormal style='text-align:justify'><span style='font-size:11.0pt'>I਀     挀愀渀 愀猀欀 昀漀爀 愀 挀漀瀀礀 漀昀 琀栀椀猀 猀椀最渀攀搀 昀漀爀洀Ⰰ 愀猀 眀攀氀氀 愀猀 愀 挀漀瀀礀 漀昀 愀渀礀 爀攀挀漀爀搀猀 
     shared.</span></li>਀ 㰀氀椀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀 猀琀礀氀攀㴀✀琀攀砀琀ⴀ愀氀椀最渀㨀樀甀猀琀椀昀礀✀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀䄀 
     photocopy or facsimile of this authorization will be valid and effective,਀     樀甀猀琀 愀猀 琀栀攀 漀爀椀最椀渀愀氀⸀ 㰀⼀猀瀀愀渀㸀㰀⼀氀椀㸀 
</ul>਀ 
<p class=MsoNormal style='margin-top:2.0pt'><span style='font-size:11.0pt'>I਀栀愀瘀攀 琀栀攀 愀甀琀栀漀爀椀琀礀 琀漀 最椀瘀攀 琀栀攀 瀀攀爀洀椀猀猀椀漀渀 搀攀猀挀爀椀戀攀搀 愀戀漀瘀攀 愀渀搀 愀洀 搀漀椀渀最 猀漀 
voluntarily.</span></p>਀ 
<p class=MsoNormal style='margin-top:3.0pt'><u><span style='font-size:11.0pt'>                                                                                    </span></u><span਀猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀甀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀⼀甀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀甀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀⼀甀㸀㰀⼀猀瀀愀渀㸀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀倀愀琀椀攀渀琀 匀椀最渀愀琀甀爀攀 椀昀 ㄀㐀 漀爀 
older                                                                        Printed਀一愀洀攀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 䐀愀琀攀㰀⼀猀瀀愀渀㸀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀 猀琀礀氀攀㴀✀洀愀爀最椀渀ⴀ琀漀瀀㨀㌀⸀　瀀琀✀㸀㰀甀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀⼀猀瀀愀渀㸀㰀⼀甀㸀㰀猀瀀愀渀 
style='font-size:11.0pt'>            <u>                                                </u>            <u>                        </u></span></p>਀ 
<p class=MsoNormal><span style='font-size:11.0pt'>Parent/Guardian/Personal਀刀攀瀀爀攀猀攀渀琀愀琀椀瘀攀 ⠀椀昀 愀瀀瀀氀椀挀愀戀氀攀⤀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 倀爀椀渀琀攀搀 一愀洀攀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 䐀愀琀攀㰀⼀猀瀀愀渀㸀㰀⼀瀀㸀 
਀㰀瀀 挀氀愀猀猀㴀䴀猀漀一漀爀洀愀氀 猀琀礀氀攀㴀✀洀愀爀最椀渀ⴀ琀漀瀀㨀㌀⸀　瀀琀✀㸀㰀甀㸀㰀猀瀀愀渀 猀琀礀氀攀㴀✀昀漀渀琀ⴀ猀椀稀攀㨀㄀㄀⸀　瀀琀✀㸀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 㰀⼀猀瀀愀渀㸀㰀⼀甀㸀㰀愀 
name="_GoBack"></a><span style='font-size:11.0pt'><br>਀刀攀氀愀琀椀漀渀猀栀椀瀀 漀昀 刀攀瀀爀攀猀攀渀琀愀琀椀瘀攀 琀漀 倀愀琀椀攀渀琀 ⠀椀昀 愀瀀瀀氀椀挀愀戀氀攀⤀ꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀꀀ 
</span><span style='font-size:8.0pt'>Rev. 11-28-2012</span></p>਀ 
</div>਀  㰀℀ⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀ 爀攀氀攀愀猀攀 ⠀瀀搀昀⤀ⴀⴀⴀⴀⴀⴀⴀⴀⴀⴀ㸀  
  <tr>਀ 㰀琀搀㸀 
਀ऀ㰀愀 栀爀攀昀㴀∀⸀⸀⼀倀䐀䘀搀漀挀⼀䨀䤀刀䄀 开刀攀氀攀愀猀攀开 ㄀㄀ⴀ㈀㠀ⴀ㈀　㄀㈀⸀瀀搀昀∀㸀䌀氀椀挀欀 栀攀爀攀 琀漀 搀漀眀渀氀漀愀搀 愀 瀀爀椀渀琀攀爀 昀爀椀攀渀搀氀礀 倀䐀䘀 搀漀挀甀洀攀渀琀⸀㰀⼀愀㸀ऀ 
</td>਀ 㰀⼀琀爀㸀 
 <!---------------- release (pdf)end ---------->਀  
   <tr>਀   㰀琀搀㸀      
       <A HREF="#TOP"> <B>(Go to Top of Page)</B></A>਀ 
਀㰀⼀琀搀㸀 
 </tr>਀                                
			</table>਀ऀऀऀ㰀⼀挀攀渀琀攀爀㸀 
<!---------------- release (form table)end ---------->਀ 
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