 to release any and all healthcare information about me to my HealthLynked personal health record (PHR) for my own uses and purposes. I acknowledge that such healthcare information may include the following: x­ rays, clinical diagnosis, histories of present illnesses, immunizations, allergies, prescription drug information, laboratory results, diagnostic screening and testing, clinical procedures, medical research, clinical trials, billing, account, and insurance information. I acknowledge that such healthcare information may include information regarding mental health screenings and/or treatment, including psychotherapy notes; HIV/AIDS, infectious disease, sexually transmitted infection testing, screening, diagnosis, and/or treatment; genetic testing; history of domestic violence, child abuse, and/or family abuse; and, substance/ alcohol use and treatment history. I acknowledge that with this authorization Dr. 