I authorize any health care provider, facility, or pharmacy that holds my records to disclose/release the following information, at the request of the individual:
All Records
To
Homestead Health
I understand that after the custodian of records discloses my health information, it may no longer be protected by federal privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment, receive payment, or eligibility for benefits unless allowed by law. By signing below, I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information.
This authorization expires 90 days after I am discharged from the services of the company named above. I may revoke this authorization in writing at any time by sending a revocation statement to the company above. I understand that the revocation will not apply to information that has already been released. I understand that authorizing the disclosure of this information is voluntary. I understand that any disclosure of information carries with it the potential for unauthorized re-disclosure by the recipient. Photocopies or facsimile of this Authorization shall be considered to be the same as a signed original document.