I, the undersigned, have read the above and authorize the staff of Lumberton Hospital, LLC to disclose such information as herein contained. I may refuse to sign this authorization and that it is strictly voluntary. I have the right to revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon it. I understand that when this information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless Lumberton Hospital, LLC, its employees, officer, staff, and its parent company form all liability and damages resulting from the lawful release of my Protected Health information. Lumberton Hospital, LLC will not condition treatment, payment, enrollment or eligibility for benefits on my completion of this form I understand that I may see and obtain a copy of the information described on this form, for reasonable copy fee. Unless otherwise revoked, this authorization will expire on the sooner of 12 months from the date of this authorization or on the date it is revoked.