Time Limit & Right to Revoke Authorization
Except to the extent that action has already been taken in reliance on this
authorization, at any time I can revoke this authorization by submitting a notice in
writing to the Privacy Site Coordinator or to the Privacy Officer. Please refer to the
Notice of Privacy Practices for appropriate mailing address. This authorization will
not expire unless revoked by you or your legal representative or upon notification of
death.
Re-disclosure
I understand the information disclosed by this authorization may be subject to
re-disclosure by the recipient and no longer be protected by the Health Insurance
Portability and Accountability Act of 1996. NASH, its employees, officers and
physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.
Signature of Patient or Personal Representative Who May Request Disclosure
I understand that I do not have to sign this authorization, and my treatment for
services will not be denied if I do not sign this form unless specified above under
Purpose of Request. I can inspect or copy the protected health information to be
requested, used, or disclosed. I authorize Network of Advanced Specialty Healthcare to request, use, and disclose the protected health information specified above.