• Authorization to Release Information:

  • 2. I understand that authorizing the release of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to ensure treatment. I understand that I may inspect or copy the information to be used or released, as provided in CFR 164.524. I understand that any release of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about the release of my health information, I can contact the organization above releasing the information.

    3. I understand that I have the right to revoke this authorization at any time. I understand that in order to revoke this authorization, I must do so in writing and present my written revocation to the organization. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire 6 months from the date of signature.

    4. I understand that I will be given a copy of this authorization form, after signing. I understand that copying charges will be applied, according to the organization’s policy.

  • Clear Signature