Right to Inspect or Copy the Health Information to be Disclosed
You have the right to inspect or copy the health information that is to be used or disclosed. You may obtain access to your health information or obtain copies by contacting the Privacy Officer. We recommend you keep a copy of your
medical records for your files.
Right to Refuse to Sign this Authorization
You have the right to refuse to sign this authorization. ENTTEX will not condition your treatment, payment, and enrollment in a healthplan or eligibility for benefits on whether you provide authorization for the requested use or disclosure.
I have had an opportunity to review and understand the content of this authorization form. By signing this authorization,I am confirming that it accurately reflects my wishes.