1. I understand that if the recipient of the information disclosed under this authorization is not a health plan or provider covered by federal or state laws, the information may be re-disclosed by the recipient and no longer protected by those laws. If the information being disclosed under this authorization contains HIV/AIDS, STD, mental health, substance abuse diagnosis and treatment, or genetic testing, Federal law and regulations including 42 CFR Part 2 and 45 CFR Parts 160 and 164 or state law may prevent the recipient from re-disclosing this information.
2. I can refuse to sign this authorization. My refusal will not adversely affect my ability to receive treatment, to enroll in a health plan, to be eligible for health care benefits, or to obtain payment for services unless this authorization is sought for purposes of research-related treatment, to determine my eligibility or enrollment in a plan, for underwriting or risk determinations or if the services related to the information to be disclosed are performed solely for the purposes of providing that information to someone else.
3. I may revoke this authorization at any time by appropriate written notification provided to the above-named disclosing entity on its designated form. Any such revocation will not apply to any activity already undertaken based on this authorization.
4. I can receive a copy of this authorization, and I may inspect and request copies of information disclosed by this authorization.