AUTHORIZATION For Davis Mobility Co to:
Use and Disclose Health Information

I understand that this organization wishes to use or disclose the following protected health information:

__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________

I understand that the following person or class of persons is authorized to use or disclose this protected health information:

__________________________________________________
__________________________________________________

I understand that this information will be used or disclosed to:

____________________________________________________
____________________________________________________

I understand that this authorization expires on:  _____________________ 
  [insert date or event]
 

I understand that I may revoke this authorization in writing.

__________________________________
Signature of Patient or Legal Representative

__________________________________
Witness

________________
Date

________________
Effective Date