Take Back ⃝ (Mark this circle with an X only if you want to WITHDRAW permission you gave earlier). Plain Language Certification of Permission and Authorization for Handling Protected Health Information The patient’s name is __________________________________. The patient was born on ___________________________. The patient’s Social Security Number or Personal Identification Number Recognized by the health care provider (enter provider name)___________________________ ______________________________________ (to be referred to as “Provider”) is (enter ID Number) ___________________. I give my permission and authorize Provider to turn over to Drew Mosley, LLC a copy of the described Protected Health Information as limited below. Further, Drew Mosley, LLC may turn over a copy of the described Protected Health Information as limited below to others as needed in the course of Drew Mosley, LLC’s representation of the patient. The purpose of this request for Protected Health Information is patient review and recordkeeping. Here are the records I want (Describe records as specifically as possible):

Here are the dates of care for which I want records (e.g., from start date to today’s date):

I get that the Provider cannot refuse treatment because I have submitted this document. I understand that and also that I can take back the permission I have given with this form. If I want to do that I just make an X in the Take Back circle above and resubmit this form with withdrawal signature line below signed. I know that to with draw permission I have to transmit this form to the party I do not want have authority to request or transmit the described Protected Health Information anymore, but I also understand it does not apply to releases or transmissions that have already been made. I do not want to give this permission or authorization forever. I only want the above permission and authorization to last from today until ______________________ (mm/dd/yyyy). I hereby give the above permission and authorization and am over the age of 18. (patient name or myself): ____________________________ ____________________________ ___________(authorizing signature). ___________________ (date). My relationship to the patient is (circle one) myself / my child over whom I have custody / my relative for whom I have power of attorney / person for whom I am executor / some other relationship. If your relationship is not myself, elaborate below in sufficient detail that legal authority to grant permission and authorization is clear: DO NOT SIGN THE BELOW UNLESS YOU SEEK TO CANCEL THE PERMISSION YOU PREVIOUSLY GAVE WITH THIS FORM.

I hereby take back and cancel the permission and authorization I previously gave above. I understand I must send this form to the party I want to take the authority back from in some provable manner, like mail, fax, etc. ________________________(signature) ____________________ (mm/dd/yyyy).