Release of Info Form

I understand and acknowledge that this may include treatment for physical and mental illness, alcohol/drug abuse and/or HIV/AIDS test
results or diagnoses. This authorization does not include permission to release outpatient Psychotherapy Notes (•) as defined below.

•Psychotherapy Notes are defined as notes that document private, joint, group, or family counseling sessions that are separated from the
rest of a patient's medical record.

This authorization and consent will expire one year after the date signed.

I understand that this authorization may be revoked at any time by notifying Privacy Officer - 4760 Belpar St NW, Canton, OH 44718, in writing,
except to the extent that OMNI Orthopaedics has taken action in reliance on this Authorization.

I understand that if the person(s) or class(es) of person(s) are not healthcare providers or health plans covered by the Federal privacy regulations, the
protected health information they receive may be further disclosed by them and may not be protected any longer by the Federal privacy regulations.

I understand that OMNI Orthopaedics may not condition treatment on the signing of this authorization.