EXHIBIT 6

NeuroCare Institute of Central Florida, P.A.

PATIENT AUTHORIZATION FOR USE AND DISCLOSURE
OF PROTECTED HEALTH INFORMATION





By signing this authorization, I authorize NeuroCare Institute of Central Florida, P.A. to use and/or disclose certain protected health information (PHI) about me to _________________________________________________________.
Name of entity to receive this information

This authorization permits NeuroCare Institute of Central Florida, P.A. to use and/or disclose the following individually identifiable health information about me (specifically describe the information to be used or disclosed, such as date(s) of services, type of services, level of detail to be released, origin of information, etc.): ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________.


The information will be used or disclosed for the following purpose:

_______________________________________________________________________.

If requested by the patient, purpose may be listed as "at the request of the individual." The purpose(s) is/are provided so that I can make an informed decision whether to allow release of the information. This authorization will expire on:

______________________________________________________________________
Expiration Date or Defined Event


The Practice will ___ will not ___ receive payment or other remuneration from a third party in exchange for using or disclosing the PHI.

I do not have to sign this authorization in order to receive treatment from NeuroCare Institute of Central Florida, P.A. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the Privacy Officer at:

    Ms. Edy Rudnick
    Practice Manager, HIPAA Compliance Officer
    NeuroCare Institute of Central Florida, P.A.
    1890 Semoran Boulevard/Suite 255
    Winter Park, FL 32792



Signed by: 

    ______________________________		_________________
Signature of Patient or Legal Guardian		Date


    _______________________________
    Relationship to Patient


    _______________________________
    Patient's Name (print)


    _______________________________
    Name of Legal Guardian


PATIENT/GUARDIAN TO BE PROVIDED WITH A SIGNED COPY OF AUTHORIZATION