Personal Health Information Disclosure and Use (PHI) / Patient Privacy/ Express Relief,LLC) Your PHI will not be used or disclosed for any purpose not listed below, without your specific written authorization. You must give written authorization to disclose your health information to anyone for any reason you want. Any specific written authorization you provide may be revoked at any time by your written request.

If approved, your records will be changed accordingly. Notification will also be made to anyone else who may have received this information and anyone else of your choosing.

If denied, you can place a written statement in your records disagreeing with the denial of your request.