This form authorizes Carla Velarde, M.D. M.P.H. to send, receive, and discuss your medical records from the provider or facility named below. Please note the following:

1. Personal health information (“PHI”) disclosed pursuant to this authorization may include information relating to mental health treatment (excluding psychotherapy notes unless separately authorized), substance use disorder treatment, and confidential HIV-related information, as protected under applicable federal and New York State laws. By signing this authorization, you specifically authorize the release of such information as described herein.
2. This authorization shall remain valid for twelve (12) months from the date of signature unless revoked earlier in writing. You understand that you may revoke this authorization at any time by providing written notice to Carla Velarde, M.D., M.P.H.; however, such revocation will not apply to information already disclosed in reliance upon this authorization.
3. A copy or photocopy of this authorization shall be considered as valid as the original.
4. You authorize Carla Velarde, M.D., M.P.H. to transmit records by facsimile, electronic mail, or other electronic means when appropriate for purposes of treatment, payment, healthcare operations, or other authorized purposes. You understand that transmission by fax or unencrypted electronic mail may carry some risk to the confidentiality of your information.
5. You understand that information disclosed pursuant to this authorization may no longer be protected by federal or state privacy laws and may potentially be redisclosed by the recipient, except where otherwise prohibited by law.
6. You understand that signing this authorization is voluntary. Treatment, payment, enrollment, or eligibility for benefits will not be conditioned upon whether you sign this authorization.
7. You understand that Carla Velarde, M.D., M.P.H. is not legally responsible for unauthorized redisclosure of information by a recipient after records have been released pursuant to this authorization.

By signing this authorization, I acknowledge that I have read and understood the contents of this form and that I am giving my permission for the release of my protected health information as described herein.