I have received and understand this authorization. I also understand that the health or health-related Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient, if permissible by law, and will no longer be protected under the appropriate federal and/or state regulations pertaining to the Information released herein.
I understand the information disclosed may include data not created by Project Quest, but that is part of my medical records, and related to the purpose of this
authorization. This information may include lab reports, radiology reports, physical and/or rehabilitative therapy notes, and progress notes.
If the information released contains drug and alcohol treatment records, the records are further protected by Federal confidentiality rules (42-CFR, Part 2 The Federal rules prohlbit the further disclosure of this Information unless further disclosure is expressly permitted by the written consent of the person to whom It pertains or as otherwise permitted by 42-CFR, Part 2. A general release of medical or other Information is NOT sufficient. Federal rules restrict any use of the information to criminally Investigate or prosecute any alcohol or drug abuse patient.
I understand that I have the right to revoke this authorization, at any time, provided that I do so in writing, and provided It is directed to the entity responsible for this authorization. If I choose to revoke this authorization, it will no longer be used for the reasons covered by this authorization. I understand that disclosures/uses/releases made prior to revoking this authorization cannot be rescinded. I understand that I do not have to sign this authorization. I understand that If I choose not to sign this authorization, my health care and payment for that health care cannot be conditioned upon receipt of this authorization and will not be affected.
To revoke this authorization, please contact your provider or Medical Records at Quest Center for Integrative Heath at 2901 E Burnside, Portland, OR 97214. Please state you are revoking this authorization.
This authorization will expire (1) 90 days from the date I am no longer in treatment within Project Quest, or (2) the date specified below: