I understand that disclosure of the information in this medical record may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV It may also include information relating to behavioral or mental health services or psychiatric treatment, treatment for substance abuse, or genetic test results.
I understand that once the information is disclosed, the information is subject to re-disclosure and may no longer be protected by the federal privacy regulations. This form may be revoked at any time providing the information has not already been disclosed. I have the right to revoke this authorization at any time. Revocation must be made by notifying, in writing, the Privacy Officer, 1790 E Venice Ave. Ste. 204, Venice, FL 34292.
I understand that this authorization will be in force and effect until the day I revoke this permission or (7) seven years from date signed below, whichever occurs first, unless otherwise specified on the following date/event/condition
I understand that my authorizing the disclosure/obtaining of this health information is voluntary. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether I sign this authorization. I understand that I may inspect or copy information to be used or disclosed as provided by law. Fees may be applied and billed by Cornerstone Psychiatric to me (patient) or if applicable to attorney, disability case vendor, insurance vendor or other vendor requesting such records. Fees are a $1.00 per page for pages 1-25 and $.25 for pages greater than 25. No fees applied when sending to /receiving from another provider of care for the purpose of Continuity of Care.
I understand the matters discussed on this form. I release the provider, its employees, officers and directors, medical staff members, and business associates from any legal responsibility or liability for the disclosure of the above information to the extent indicated and authorized herein.