· My record may contain information regarding the screening for HIV (human immunodeficiency virus), other bloodborne pathogens (Hepatitis B, Hepatitis C), or sexually transmitted diseases. I give my specific authorization for these records to be released.
· Only records maintained by Missoula Public Health will be released.
· With written consent on file, immunization records from the State Registry imMTrax, also can be released.
· I have the right to revoke this authorization at any time. Revocation must be done in writing. I understand that I cannot revoke an authorization for information that has already been released in response to this authorization.
· This authorization is voluntary. I can refuse to sign this authorization. I need not sign this authorization to receive treatment, payment for services, enrollment, or eligibility for benefits.
· I may inspect or copy this authorization provided in 45 CFR 164.524. I understand that any disclosure of information under this authorization carries with it the potential for an unauthorized re-disclosure by the recipient and, after it is disclosed, the information may not be protected by state or federal confidentiality rules. If I have questions about disclosure of my health information, I can contact Missoula Public Health's Health Services Division Director.