I hereby authorize NEXT | HEALTH Corp ​to release information from my medical records to my employer CaliWater LLC.

SPECIFICALLY:
This authorization expires in sixty (60) days from the date signed below and covers only treatment for dates specified above. If records are not picked up within sixty (60) days, they will be disposed of in a secure manner.

By Selecting 'I Agree' I acknowledge and agree to the above conditions.

THIS AUTHORIZATION WILL NOT BE VALID UNLESS ENTIRELY FILLED OUT NOTICE TO RECIPIENT: ​

The recipient of the enclosed information is not authorized to use patient’s medical record information for any purpose other than for that stated above or to disclose any information to any other person or facility.