The information released shall include:
I understand that this information will be used for:

I acknowledge that the doctrine of Informed Consent has been explained to me and I understand the contents to be released, the need for the information, and that there are statutes and regulations protecting the confidentiality of authorized information. I acknowledge that this consent is truly voluntary and is valid for one year. I further acknowledge that I may revoke this consent to release information, in writing, at any time except to the extent that action based on this consent has been taken. I understand that Dr. Tracy L. Helmer will handle all information in adherence to all confidentiality regulations, including HIPAA.