This authorization will expire in 1 year from date of Signature
I understand that I may revoke this authorization at any time by notifying my provider or by notifying the provider or entity that is authorized to receive this records. I understand that revocation will not have any effect on the actions taken prior to any revocation and will not apply to information that has already been released in response to this authorization.
The authorization is voluntary. I can refuse to sign this authorization.
I understand that if the organization authorized to receive the information is not a health plan or a health care provider, the information may no longer be protected by federal privacy regulations.
I understand that this information may be re-release by the recipient and no longer protected.
I understand that the provider named above may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.
If mental health records are being release as permitted by the Mental Health Procedures Act, I understand that I have a right, subject to 55 Pa. Code 5100.33 to inspect the material being released.
If AIDS of HIV- related information is being released, this information has been disclosed to you from records protected by Pennsylvania law. Pennsylvania law prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, or is authorized by the Confidentiality of HIV- Related Information Act. A general authorization for the release of medical or other information is not sufficient for this purpose.
By signing below, I certify that I understand the nature of this release.