I, {patientName}, hereby authorize {providerName} to release all of my medical records including but not limited to office notes, test results, outside physician reports, and chemotherapy regimens to The Oncology Institute of Hope and Innovation.
The authorization is in effect until six months from the date of the signature below, at which time it expires. I understand that by signing this authorization:
- I authorize the use or disclosure of my individually identifiable health information as described above for the purpose listed. I understand that this authorization is voluntary.
- I understand the Notice of Privacy Practices provides instructions should I choose to revoke my authorization.
- I understand if the organization I have authorized to receive the information is not a health plan or healthcare provider, the released information may no longer be protected by federal privacy regulations.
- I understand I have the right to receive a copy of this authorization.
- I understand that I am signing this authorization voluntarily and that treatment, payment, or eligibility for my benefits will not be affected if l do not sign this authorization.
I declare under penalty of perjury that the information on this form is true and correct.