Authorization: I hereby authorize the release of my medical records or medical records (for the patient indicated above if minor or guardianship) involved, covering all medical records regarding treatment, impatient and outpatient care. I release that this may specifically include information about psychological or psychiatric conditions: drug abuse, alcoholism, Acquired Immune Deficiency Syndrome and/or human immunodeficiency virus. (New York State law requires these conditions to be specified, my signature does no imply that any of them apply to me
Patient's Right to Revoke: I understand that I may revoke this authorization at any time by writing a letter to the provide stating my authorization is revoked. The letter must be addressed to the "Privacy Officer" at the providers' current address. However, if the provider has relied on my authorization and has taken action on my protected health information, my revocation shall not be
Redisclosure by Recipient: I understand that once the provider discloses the protected health information to a recipient, the recipient may redisclose the information which may no longer be protected by the federal or state law.
Acknowledgement of Reading and Agreement: By signing below, I agree that I have read and understand this authorization. If a representative of the patients signs this authorization, i.e., guardian/parent, the representative has the authority to act on behalfof the patient.