Evolutionary Healthcare

Patient Name * Patient Date of Birth * Address * City, State, Zip * SSN * Primary Phone Number *

By my e-signature below, I authorize the release of the Protected Health Information (PHI) indicated below to Evolutionary Healthcare from:

Physician / Facility Name * Phone Number * Fax Number Address City, State, Zip The reason for this disclosure is: * If "Other", please specify:

Release the Following Information:

Check if yes Information for the date(s) of service: Information related to the following treatment or condition: Other (e.g. x-rays, bills, etc.), specify dates: Specific authorization is required for release of information pertaining to the below listed items. If items are not specifically indicated, no information will be released.

Authorization Details

This authorization ends: * If other, please specify:

Patient Rights

I understand that I do not have to sign this authorization in order to get health care benefits (treatment, payment or enrollment). However, I do have to sign an authorization form: - To receive health care when the purpose is to create health care information for a third party or - To participate in a research study. I may revoke this authorization in writing. If I do, it will not affect any actions already taken by Evolutionary Healthcare based upon this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. Two ways to revoke this authorization are: - Fill out a revocation form available from Evolutionary Healthcare or - Write a letter to Evolutionary Healthcare. Once health care information is disclosed, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect the health care information.

E-Signature * Date *