Release of Information Disclaimer

• By signing this Release of Information form, you consent to the release of your personal, medical, financial, or other specified information to the designated recipient. This authorization is voluntary, and you have the right to refuse to sign without facing any penalties or negative consequences regarding the provision of services.
• You understand that once the information is released, the recipient may use or disclose it for the purposes outlined in this form. However, we do not control how the recipient will handle your information, and once disclosed, it may no longer be protected by the privacy laws governing its original use.
• You also acknowledge that the accuracy of the information disclosed cannot be guaranteed, and the provider is not liable for any loss, damage, or harm resulting from the use of this information once released. You have the right to revoke this authorization at any time by submitting a written request to the entity holding your information. This revocation, however, will not affect any actions taken before the revocation.
• The authorization will remain valid until the expiration date indicated or the purpose for which it was granted has been fulfilled. By signing, you confirm your understanding of these terms and agree to the release of your information as specified.
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