In accordance with the doctrine of informed consent, I understand the contents of the information to be used/disclosed/exchanged, the need for the information, and that there are statutes and regulations protecting the confidentiality of authorized information. Redisclosure of protected health information is prohibited except as permitted or required by State or Federal Laws. I understand that, with certain exceptions, I have the right to revoke this authorization at any time. If I revoke this authorization, I must do so in writing. The procedure for how I may revoke this authorization, as well as the exceptions to my right to revoke, are explained in the provider’s Notice of Privacy Practices, a copy of which has been provided to me (See reverse side of form). I understand that I may refuse to sign this authorization form. If I choose not to sign this form, I understand that provider cannot deny or refuse to provide treatment, payment, enrollment in health plan, or eligibility for benefits on my refusal to sign unless the provision of health care is solely for the purpose of creating protected health information for disclosure to a third party on provision of an authorization for the disclosure of the protected health information to such third party.