FPA is unable to discuss your treatment with anyone unless you give us written permission.
Health Information to be disclosed upon the request of the person named above -- (Check either A or B):
- Mental health records
- Communicable diseases (including HIV and AIDS)
- Alcohol/drug abuse treatment.
This authorization shall be effective until terminated by me. (NOTE: You may revoke this authorization in writing at any time by notifying your health care providers, preferably in writing.)