While Cedarville University will use reasonable good faith efforts to ensure record privacy, I understand that the Patient History Information authorized to be disclosed.
Any and all information with respect to any illness, medical history, immunizations, consultations, prescription, treatment, and copies of all hospital or medical records for the specific purpose of involvement in my medical care, may be re-disclosed to additional parties and no longer protected for reasons beyond our control.
I understand I have the right to: Revoke this authorization by sending written notice to this office and that revocation will not affect this office's previous reliance on the uses or disclosure pursuant to this authorization. Knowledge of any renumeration involved due to any marketing activity as allowed by this authorization, and as a result of this authorization. Inspect a copy of Patient Health Information being usued or disclosed under federal law. Refuse to sign this authorization. Receive a copy of this authorization. Restrict what is disclosed with this authorization.
I also understand that if I do not sign this document, it will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits whether or not I provide authorization to use or disclose protected patient health information. A photo copy of this authorization shall be considered as effective and valid as the original.