Authorization for Release of Medical Information

I understand that my health care will not be affected if I do not sign this form.

I understand that this authorization will expire one year from the date of my signature below, whichever is earlier.

I also understand that I may revoke this authorization at any time by notifying Hill Physicians in writing. I understand that my revocation of this authorization will not affect any actions taken by Hill Physicians in reliance on this authorization prior to the time it received my revocation.

I understand that I have the right to receive a copy of this authorization.