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Medical Release

General Information Regarding This Authorization: This Authorization permits Virginia Infusion Therapies to use or disclose your Protected Health Information for purposes other than your treatment,  payment to Virginia Infusion Therapies or the health care operations of Virginia Infusion Therapies. You have the right to revoke this Authorization by providing Virginia Infusion Therapies with written notice of revocation. The revocation will be effective upon receipt by Virginia Infusion Therapies, except with respect to uses or disclosures made prior to receipt and in reliance upon this Authorization.

Virginia Infusion Therapies cannot require you to sign this Authorization as a condition to the provision of services. Please note that once the requested information is disclosed pursuant to this Authorization, Virginia Infusion Therapies will no longer have control over the information and there is a potential that it may be re-disclosed by the recipient.