hereby authorize and request the release of my medical records to/ from My Omni Housecalls. I may revoke this consent at anytime and this consent will automatically expire ninety (90) days from signature below. I will accept responsibility for reasonable copy fees charged by the office releasing records on my behalf pursuant to NC Law 90-32. Records from other health facilities should be obtained from the original source. This notice hereby releases the sender from all legal responsibility or liability of the release of information described in this release.