I understand that once my health care provider discloses my health information to the recipient(s) identified above, my health care provider cannot guarantee that the recipient(s) will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.
I understand that I may refuse to sign or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of my treatment by my health care provider.
I understand that the Authorization will remain in effect until the term of this Authorization expires or I provide a written notice of revocation to my health care provider at my health care provider’s regular office address. The revocation will be effective immediately upon my health care provider’s receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before the provider received my written notice of revocation.
I may contact my health care provider for answers to my questions about the privacy of my health information at my health care provider’s regular office telephone number. I understand that I have a right to receive a copy of this Authorization from my health care provider.
A photocopy, fax or electronic copy of this Authorization shall be considered as effective and as valid as the original.