Medical Disclosure Form Pella Pilates & Wellness, LLC Medical Disclosure Form * I hereby authorize the use or disclosure of my health information as described below. I understand the information disclosed under this authorization may be subject to redisclosure by the recipient and no longer protected by federal privacy regulations. Today's Date MM DD YYYY Email * Address * Street Address, City, State, Zip Phone * (###) ### #### Date of Birth * Covering the period (s) of health care: * From (Date): MM DD YYYY * To (Date): MM DD YYYY Information to be disclosed * (check as many as appropriate): I specifically consent to the release of any information related to testing and treatment for HIV, AIDS, mental health/psychiatric care, or alcohol and/or drug abuse if such is contained in the medical records. THIS PROVISION MUST BE INITIATED BY PERSON GIVING CONSENT OR THIS INFORMATION WILL NOT BE RELEASED. Health Records History and Physical Examinations Consultation Reports X-Ray Reports Initials * Type your initials here: This information is to be disclosed to: * Full Name and Address: for the purpose of: * This authorization will expire on: * , not to exceed 1 year. I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization. If I fail to specify a date or otherwise revoke this authorization, this authorization will expire 1 year from the date signed below. MM DD YYYY Typing my name below acts as my signature: * If client is under 18 years old, legal parent or guardian must sign. First Name Last Name Thank you! Your form has been submitted.