- I understand that this release is voluntary and that I may refuse to sign this authorization.
- If the person or organization I authorize to receive the information is not subject to federal health information privacy laws, they may further release the protected health information and it may no longer be protected by the federal privacy laws.
- I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken before the revocation is received.
- My treatment, payment for healthcare, enrollment in a health plan or eligibility for benefits may not be conditioned on signing this authorization.
- I may see and copy the information described on the form upon my request.
- I may refer to the Notice of Privacy Practices to get more in-depth information regarding my privacy rights.
I have carefully read and understand the above statements and do herein expressly and voluntarily consent to disclosure of the above informaton about, or medical records of, my condition to those persons or agencies named above.