Methods of Disclosure Authorized: Faxed, written, phone conversation, in‐person and/or secure e‐mail
- I understand that I may revoke (withdraw) this authorization at any time by notifying the practice in writing. Revocation will be effective as of date received.
- I understand that a revocation will not apply to: 1)any actions that this practice has already taken while relying on this authorization before I revoke it; or 2) if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right
- I understand that I might be denied services if I refuse to consent to disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to disclosure for other purposes.
- I understand that the recipient of some information disclosed under this authorization may re-disclose this information and that the information will no longer be protected by federal privacy regulations.
- I understand that I have the right to: 1) Inspect or copy the protected heath information to be used or disclosed as permitted under Federal law; 2) Refuse to sign this authorization.
- This authorization will remain in effect for one year and may be revoked at any time by notifying this practice in writing.
- Unless otherwise noted, only the past two years of electronic records as stipulated above will be sent.