Competency II$\mathrm{.}3$found missing.PINE VALLEY COMMUNITY HOSPITALAUTHORIZATION TO RELEASE HEALTH INFORMATIONDate of Birth:Patient's Name:Patient's Social Security Number:Thereby authorize Pine Valley Medical Center to release to the following:Name:Address:Documents to be released are:From Date of Service:Purpose for record request is:I understand that applicable laws may prohibit redisclosure of this information, but that PYMC will nor be liable or responsible for any redisclosure that takes place after the information has been released.I understand that I will not be denied treatment if I refuse to sign this authorization.I understand that I am entitled to a copy of this authorization.I understand that the information will be handled confidentially in compliance with applicable state and federalJaws.I have read and understand the nature of this release.Patient's Signature$/$Legal RepresentativeDateWitnessDateesourcenehar$-$Thompson, I. A$.2017.$ The HIPAA Privacy Rule: Part $1.$ Chapter $10$ in