I hereby authorize the use or disclosure of the following individual’s health information as described below:

I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and resend my written revocation to the HIPPA Compliance Officer. 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 revokes my insurer with the right to contest a claim under my policy, unless otherwise revoked. I understand that authorizing this disclosure of health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect a copy of the information to be used or disclosed as provided in 45 CFR 164.524. I understand that any disclosure of information carries with it the potential for unauthorized re-disclosure and the information may not be protected by federal confidentially rules. If I have any questions about the disclosure of health information I can contact the HIPPA Compliance Office at CHCCW. I understand there could be a fee associated with the reproduction of my medical records. I understand by signing this authorization I am required to pay for the reproduction of my medical records in advance, even in the event I decide to cancel my request. In accordance with HIPAA standards, CHCCW will not bill me for the retrieval of my medical records

***PLEASE ALLOW UP TO TWO WEEKS FOR RECORDS TO BE SENT. ***