NOTICE OF PRIVACY PRACTICE AND INSURANCE RELEASE FORM

I have reviewed a copy of the Notice of Privacy Practices. A copy of the privacy

practice is available upon request.

I authorize any holder of medical information about me to be released to determine benefits or the benefits payable for related services. This assignment will remain in effect until revoked in writing. A photocopy of this assignment is considered to be as valid as the original.

I _________________________________ have read and understand the above sections.

_____________________________________         _______________________

Signature                                                 Date