Authorization for Use and Disclosure of Protected Health Information

hereby authorize Racheal Home Health Care Inc. (hereafter collectively referred to as "Agency") to use and disclose in any form or format, a copy of records concerning

but only as follows. A copy of this signed, dated Authorization shall be as effective as the original. Agency may use and disclose the following information.

The undersigned does hereby release, hold harmless, and agree to indemnify Agency, its employees, and agents for any and all liability (including but not limited to negligence) arising out of or occurring under this authorization. I understand that my records may be subject to re-disclosure by recipient(s) and unprotected by federal or state law; that this authorization remains effective until Agency is in actual receipt of a signed revocation or until the records retention period, required under federal and state law, has expired and the records have been destroyed; that I have the right to revoke this authorization at any time, provided I do so, in writing; that I have been given an opportunity to ask questions; that I have received a copy of the signed authorization; that I may inspect a copy of my protected health information to be used, or disclosed, under this authorization; that the Agency has not conditioned provision of services to, or treatment of, me upon receipt of this signed authorization; and that I may refuse to sign this authorization.