I voluntarily consent to have the Summit County Combined General Health District ("Health District" or "District") treat me, provide me with services, and bill me and/or my insurance for services/treatments provided to me. I understand that the receipt of any services is not a prerequisite for the receipt of any other services. I have received the District’s Notice of Privacy Practices and understand that these explain how the medical information of the patient may be used and disclosed. Except for research-related treatment and treatment solely for the purpose of disclosure to a third party, treatment or payment, enrollment or eligibility for benefits may not be conditioned on execution of this authorization. I understand that I may receive an accounting of disclosures upon request. I acknowledge that this authorization is voluntary and I may revoke the authorization orally, in the box below, in writing to the Health District Privacy Officer at 1867 W. Market St Akron, OH 44311, or by emailing hipaa@schd.org. I understand that I cannot revoke consent for releases where the District has already reasonably relied upon my consent. I understand and acknowledge that this Authorization extends to all or any part of the records designated above, which may include treatment for mental illness (ORC5122.31), and/or Human Immunodeficiency Virus (HIV/Acquired Immune Deficiency Syndrome AIDS) test results or diagnoses (ORC3701 243). This form has been fully explained to me and I certify that I understand its contents. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA. I am giving this authorization pursuant to both HIPAA and ORC 3701.17. I consent to virtual, telephonic, or electronic ("telehealth") visits in whatever secure form that the District may provide. I expressly waive any claim against the District related to telehealth visits. I agree that the electronic signature on this form is sufficient for all legal purposes and I waive all rights to any claim related to any requirement of physical signatures on anything affected by this electronic signature. It is my desire that my electronic signature be as effective as a physical signature.

I understand and acknowledge that this authorization extends to all or any part of the records designated above, which may include treatment for mental illness (ORC 5122.31), alcohol/drug use and/or abuse (42 CFR Part,2), and/or Human Immunodeficiency Virus (HIV/Acquired Immune Deficiency Syndrome AIDS) test results or diagnoses (ORC 3701.243).