AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION IN CONNECTION WITH ELIGIBILTY FOR ADMISSION AND CONTINUED STAY AT COLONIAL HEALTH & REHAB CENTER OF PLAINFIELD, LLC

To: All providers of medical and dental services or supplies and their representatives, the Medical Information Bureau, Inc. or other organizations, all insurers, medical or hospital service plans, prepaid health plans.

For purpose of determining eligibility for admission and continued optimal medical care, I authorize you to furnish Colonial Health & Rehab center of Plainfield, LLC or its representatives performing business or legal functions, any information available about my medical history, condition and treatment.