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INDIAN RIVER COUNTY INDIVIDUAL AUTHORIZATION FORM AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION I hereby authorize the use or disclosure of my health information as described in this authorization, is authorized to provide the information. (Specific person/organization) is authorized to receive and use the information: (Specific person/organization) The specific description of the information is . Right to revoke: I understand that I have the right to revoke this authorization at any time by notifying the Indian River County' s Health Benefits Administrator (Ann Rankin, 567. 8000) in writing at the Human Resources Department, Fax 772. 770. 5004, Address 1840 25th Street Vero . Beach, Fl 32960 . I understand that the revocation is only effective after it is received and logged by the Benefit/Payroll Administrator. I understand that any use or disclosure made prior to the revocation under this authorization will not be affected by a revocation. I understand that after this information is disclosed, federal law might not protect it and the recipient might re-disclose it. I understand that I am entitled to receive a copy of this authorization. I understand that this authorization will expire when my employment with Indian River County terminates and for all others such as retirees on this date : M/D/Y Signature of Employee Date Personal Representatives section If a Personal Representative executes this form, the Representative warrants that he or she has authority to sign this form on the basis of: