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. This authorization will
automatically expire upon notification of my death.
Re-disclosure
I understand the information disclosed by this authorization and any re-disclosure by NASH is subject to HIPAA. I hereby authorize NASH to disclose my personal information, including elements of my medical record, to its employees, officers, and contracted physicians, as well as to respond to requests from government authorities (e.g. border patrol) and to use my personal information to the extent necessary to connect me with my medication.
Signature of Patient or Personal Representative Who May Request Disclosure
I understand that I do not have to sign this authorization, but that decision may impact my ability to access NASH’s services. I can inspect or copy the protected health information to be requested, used, or disclosed. I authorize NASH to request, use, and disclose the protected health information specified above.