• AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

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  • 4. This authorization expires twelve (12) months from the date of my signature below. 

  • 5. I understand that:

    • The federal Privacy Rule (HIPAA) does not protect the privacy of information if re-disclosed and therefore request that all information obtained be held strictly confidential and not be further released by the recipient . I intend this document  to be a val id authorization conforming to all requirements of the Privacy Rule and state laws.
    • I may revoke this consent at any time by completing a written Revocation of Release of Information Form . Revoking  this authorization does not apply to information that al ready has been released under this authorization.
    • I need not consent to the release of information in order to obtain services. I choose to do so willingly for the  purpose(s) specified above.
    • My signature below asserts and confirms my legal authority to sign on behalf of the minor.

     

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