Redisclosure
I understand that once my health care provider discloses my health information to the recipient identified above, my health care provider cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.
Refusal to Sign/Right to Revoke
I understand that I may refuse to sign or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of my treatment by my health care provider.
Revocation
I understand that the Authorization will remain in effect until the term of this Authorization expires or I provide a written notice of revocation to my health care provider at my health care provider’s regular office address. The revocation will be effective immediately upon my health care provider’s receipt of my written notice.
Questions
I may contact my health care provider for answers to my questions about the privacy of my health information at my health care provider’s regular office telephone number. I understand that I have the right to receive a copy of this Authorization from my health care provider.
Photocopy
A photocopy, fax, or electronic copy of this Authorization shall be considered as effective and as valid as the original.
Term
This Authorization will remain in effect for one (1) year from the date this Authorization is signed.
By signing this document, I hereby declare that I understand and acknowledge that I am giving authorization to the use and/or disclosure of my protected health information as described and for the purpose specified above.
I am signing this authorization voluntarily. I understand that I have the right to withdraw my permission or withdraw my authorization at any time by writing. In case I withdraw my authorization, I understand that any benefits, treatment, or eligibility shall not be affected.
Further, I understand that this authorization may not further be used by the person or entity to whom my medical records are to be disclosed, to use or disclose the said information to another unless otherwise permitted in writing or unless such intended disclosure is required or permitted by law.