Describe in detail the Protected Health Information you are authorizing to be used and/or disclosed

Describe in d each purpose for which you are authorizing your Protected Health Information to used and/or disclosed.

Name of Doctor Receiving PHI to receive and use the information. This authorization will end when my current treatment plan is completed or one year from the date signed below. I understand that once the information is released it may be redisclosed by the recipient and may no longer be protected by federal privacy regulations, I understand that I may revoke this authorization at any time by notifying. In writing, the above-named doctor disclosing the PHI. However, if I do revoke this authorization, it will not have any effect on any actions taken by the above-named doctor disclosing the PHI prior to their receipt of the revocation. I understand that my treatment cannot be conditioned on whether I sign this authorization. I understand I may refuse to sign this authorization.