I understand that state and federal laws permit certain uses and disclosures for treatment, payment and health care operations without my consent and these have been explained in the Notice of Privacy Practices that has been provided to me. I understand that the health information used and disclosed may include information such as HIV infection, AIDS or AIDS-related conditions, alcohol abuse, drug abuse, psychological or psychiatric conditions, or genetic testing, if applicable.
I understand this consent is valid for the period of time needed to fulfill its purpose for up to one year, except for disclosures for payment purposes, wherein the consent is valid until the need for disclosure is satisfied. I understand that I may revoke this consent at any time, except to the extent that action has been taken in reliance on it, and that I will be asked to sign the Revocation Section on the back of this form. I further understand that any action taken on this consent prior to the rescinded date is legal and binding.
A copy of this consent shall be considered as valid as the original.
By typing my name into this form, I am providing my electronic signature.