AUTHORIZATION FOR THE DISCLOSURE OF HEALTH INFORMATION TO DR. B MEDICAL GROUP

Completion of this document authorizes the use and disclosure of health information about you. Failure to provide all information requested may invalidate this Authorization.

I hereby authorize Cloud Health Systems, Inc. (“Sunrise”), M & D Integrations, Inc. DBA MD Integrations (“MDI”) and/or any physician or health care provider engaged, contracted, employed or managed by Sunrise or MDI (each, a “Disclosing Entity”) to disclose my entire medical record and all health information pertaining to my medical history, mental or physical condition, and treatment received, including demographic information, to Dr. B Medical Group (DE), P.A., and all members of its affiliated covered entity (collectively, “Dr. B Medical Group”). I authorize the release of this information in order for Dr. B Medical Group to provide services to me. I understand this disclosure may include information regarding my psychiatric/mental health, substance use disorders, developmental disabilities, HIV/AIDS, and/or sexually transmitted diseases. I give my specific authorization for these records to be disclosed. This Authorization is valid for five (5) years from the date I sign this Authorization or for the duration permitted under applicable state law, whichever is earlier.

I understand that I have the right to revoke this Authorization, in writing, at any time by sending such written notification to Dr. B Medical Group, except to the extent that Dr. B Medical Group has already acted in reliance on my Authorization. I understand that information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient of such information and may no longer be protected by federal or state law. However, state law may prohibit the person receiving my health information from making future disclosures of my information unless another authorization for disclosure is obtained from me, or unless such disclosure is specifically required or permitted by law. Neither Dr. B Medical Group nor any Disclosing Entity will condition my treatment on whether I provide authorization for the requested use or disclosure. I understand that I have the right to refuse to sign this Authorization and the right to receive a copy of this Authorization.

By clicking “I consent”, I acknowledge I have read the above information and authorize the disclosure of my information to Dr. B Medical Group for the purpose described herein.