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RELEASE OF INFORMATION DISCLAIMER

I understand that by digitally acknowledging and signing this document, I am voluntarily waiving my rights under the Health Insurance Portability and Accountability Act (HIPAA) and am allowing Dr. Feldman and UCS (hereinafter referred to as "the Provider") to share my medical reports, charts, and other relevant data with relevant recipients, including but not limited to, my bariatric center, doctor, hospital, or other relevant institution. I understand that the information shared may include sensitive medical information that could potentially be used to identify me.

I understand that I have the right to revoke this release of information at any time by providing written notice to the Provider. I understand that revoking this release of information will not affect any actions taken by the Provider before receiving notice of my revocation.

I understand that the Provider is only releasing information that is necessary for the recipient to provide me with appropriate care and treatment and that the Provider will not release more information than is necessary for this purpose.

I acknowledge that I have been informed of my rights under HIPAA and have received a copy of the Provider's Notice of Privacy Practices. I have also been given the opportunity to ask questions and have had any questions answered to my satisfaction.

I acknowledge that I have read and fully understand the above Release of Information Disclaimer and voluntarily agree to its terms.

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