• AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION

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  • Clinic/Hospital/Health Care Provider (Who has the information you want released? Please list the specific clinic or provider.)

  • Receiving Party (Where do you want the information sent? Who may have the information? If you are releasing information to yourself, please list "self".)

  • Information to be Released (What do you want sent or released? Check the appropriate box.)

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  • Release Instructions

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    • You may cancel this authorization at any time by writing to Family Tree Clinic. A cancellation will not change releases that happen before the cancellation
    • A photocopy/fax of this authorization will be treated in the same way as an original.
    • Family Tree Clinic may include records that it received from other organizations. If these records have been used by Family Tree Clinic and filed in the record Family Tree Clinic maintains about you, these records may be released with your Family Tree Clinic records.
    • Family Tree Clinic cannot prevent redisclosure of your information by the person or organization who receives your records under this authorization, and that information may not be covered by state and federal privacy protections after it is released. By signing this authorization, you release Family Tree Clinic from any and all liability resulting from a redisclosure by the recipient.
    • Family Tree Clinic will not condition treatment, payment, enrollment or eligibility for benefits on whether or not you sign this form.
    • Your signature indicates that you have read and understand this form, and authorize release of your information as described above
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