Authorization to release health information

I authorize the licensed provider who treats me through Evolve Prime Health to share my health information with the licensed pharmacy that fills my prescription, and with the people and services needed to provide, bill for and support my care, as described in the Notice of privacy practices. This authorization covers my assessment answers, prescriptions, order details and related records. It stays in effect while I receive care through Evolve Prime Health unless I revoke it in writing to support@evolveprimehealth.com. Revoking it doesn't affect information already shared. My care does not depend on authorizing any marketing use of my information.