• This is a full release including information related to behavioral/mental health, drug, and alcohol abuse treatment (in compliance with 42 CFR Part 2), genetic information, HIV/AIDS, and other sexually transmitted diseases. If my record contains information relating to HIV infection, AIDS or AIDS-related conditions, alcohol abuse, drug abuse, psychological or psychiatric conditions, or genetic testing this disclosure will include that information. Once released, my information may not be protected from re-disclosure by the requester of the information; however, if this information is protected by the Federal Substance Abuse Confidentiality Regulations, the recipient may not re-disclose such information without my further written authorization unless otherwise provided for by state or federal law.
• Refusing to sign this authorization will not affect my ability to obtain treatment, payment for services, or my eligibility for benefits; however, if a service is requested by a non-treatment provider (e.g., insurance company) for the sole purpose of creating health information (e.g., physical exam), service may be denied if authorization is not given. If treatment is research-related, treatment may be denied if authorization is not given.
• FIPP will not share or use my health information without my permission other than by ways listed in the Notice of Privacy Practices or as required by law. https://hipaa.jotform.com/app/230444503777154
• I further understand that I may request a copy of this signed authorization.
• I may revoke this authorization at any time by signing the FIPP Revocation of Consent Form, which may be found at https://form.jotform.com/200926657352054.
• I further understand that any action taken on this authorization prior to the rescinded date is legal and binding.
• If I fail to specify an expiration date, event, or condition, this authorization is valid for the period needed to fulfill its purpose up to one year, except for disclosures for financial transactions, wherein the authorization is valid indefinitely.