The specific PHI to be used/disclosed shall include only the minimum information necessary to assist in the above stated purpose.
- I understand the information to be used/disclosed may be communicated in written, verbal, or electronic form.
- I understand that substance use information is protected by federal regulations and cannot be released without my authorization (above).
- I understand the information to be used/disclosed may contain HIV/AIDS information.
- In accordance with the doctrine consent, I understand the consent of the information to be used/disclosed, the need for the information, and that there are statutes and regulations protecting the confidentiality of authorized information.
- Redisclosure of protected health information in prohibited except as permitted or required by state or federal laws.
- I understand that I may revoke this consent in writing at any time except for those actions taken prior to revocation.
- I understand that I may refuse to sign this authorization form.
- I hereby acknowledge that this consent is truly voluntary.
By signing my name and printing the date in the boxes below, I hereby consent to the terms of this document.