* 1. I hereby request and authorize the use and disclosure of any and all information obtained through Physicians CareConnection (including but not limited to protected health information and records of substance abuse (including alcohol/drug abuse), mental health/illness and HIV related information (including AIDS testing) to Care Coordination Network and its network of care coordination agencies.) I understand that this protected health information will be collected and stored in Care Coordination Network's Pathways HUB Connect Data System. This authorization will expire 2 year(s) from the date of my signature below. I understand that I may shorten, extend or revoke this authorization at any time by notifying Care Coordination Network, Attn. Program Director, 360 South Third Street Columbus, OH 43215. This authorization and request is fully understood and is made voluntarily on my part. I release Care Coordination Network, its employees, agents and representatives of any legal liability that may arise from the release of information.

* 2. Enter Your or Minor's Full Name (First, Middle, and Last Name) Below:

* 3. If you are the parent or legal guardian of the minor, please fill in your FULL NAME (First, Middle and Last Name):

* 4. If you are the parent or legal guardian of the minor, please state your relationship to the minor: