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By checking this box I hereby authorize Dendro Technologies, Inc (“Dendro") to release and disclose the information that I have provided here and in response to future surveys to UnitedHealth Group (“UHG"), which I understand is the healthcare insurer that initially referred me to Dendro. I understand that UHG may use this information for purposes including arranging for my continued care, treatment, payment, and health care operations. I understand that, once disclosed, this information may no longer be protected by state or federal privacy regulations. I may revoke this authorization at any time by notifying Dendro in writing at However, if I revoke this authorization, I understand that it will not have any effect on any disclosures to UHG which Dendro made before it received the revocation. I acknowledge that Dendro is not receiving payment from UHG in exchange for the information that I have provided in response this forms and the these surveys.