II. My Rights
I understand I do not have to sign this authorization in order to receive treatment. However, I may be required to sign this authorization form:
To take part in a research study; or
To receive health care when the purpose is to create health information for a third party.
I may revoke this authorization at any time, in writing, sent to Nancy Chen, M.D. and/or Kapolei Eye Care at the address provided below. If I do, it will not affect any actions already taken by Nancy Chen, M.D. and/or Kapolei Eye Care based upon this authorization; uses and disclosures already made cannot be taken back. I may not be able to revoke this authorization if its purpose was to obtain insurance.
Nancy Chen, M.D., Kapolei Eye Care
511 Manawai St, Unit 401, Kapolei, HI 96707
Once the office discloses health information, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.
I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.
This authorization is valid for one year from date signed.