I Hereby Authorize ZA Management to obtain and release requested records
The individual authorizing this form agrees and acknowledges as follows
Voluntary Authorization: This authorization is voluntary. Treatment, payment, enrollment or
eligibility for benefits (as applicable) will not be conditioned upon my signing of this
authorization form.
Effective Time Period: This authorization shall be in effect until two (2) years after the death
of the patient for whom this authorization is made.
Right to Revoke: I understand that I have the right to revoke this authorization at any time by
writing to ZA Management. I understand that I may revoke this authorization except to the extent
that action has already been taken based on this authorization.
Special Information: This authorization may include disclosure of information relating to DRUG,
ALCOHOL and SUBSTANCE ABUSE, MENTAL HEALTH INFORMATION, PSYCHOTHERAPY, NOTES, CONFIDENTIAL
HIV/AIDS-RELATED INFORMATION, and GENETIC INFORMATION only if I accept these terms. In the event
the health information described above includes any of these types of information, and I accept
these terms, I specifically authorize release of such information to the person or entity
indicated herein.
Signature Authorization: I have read this form and agree to the uses and disclosure of the
information as described. I understand that refusing to authorize this form does not stop
disclosure of health information that has occurred prior to revocation or that is otherwise
permitted by law without my specific authorization or permission. I understand that information
disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may
no longer be protected by federal or state privacy law
