Authorization expires: _________________________(date) If no date is indicated, the Authorization
|Authorization for Release of Mental Health
Milton Huang, M.D.
740 Front Street, suite 335
Santa Cruz, CA 95060
will expire 12 months after the date of my signing this form.
- I understand that I may revoke this authorization at any time by making a written request to Dr.
Huang, except to the extent that action already has been taken in reliance on this authorization.
- I understand that my signing is voluntary, and Dr. Huang may not condition treatment or payment on
my signing this authorization. A third party may require this authorization to obtain information in
connection with eligibility or enrollment in a health plan, or to determine their obligation to pay a claim.
- I understand that information disclosed based on this authorization may be subject to redisclosure by the
recipient of this information, and no longer protected by federal privacy regulations.
- I understand I am entitled to receive a copy of this Authorization.
Signature (patient or authorized representative) _______________________________________
Relationship/authority (if signed by authorized representative): _________________________
Witness (only if patient unable to sign): ___________________________________________