I understand that medical information may include if applicable: Alcohol and/or drug abuse and/or mental health treatment information protected under the regulation in Title 42 of Code of Federal Regulations Part II. Information about Human Immunodeficiency Virus - HIV, acquired immunodeficiency syndrome - AIDS, and AIDS related complex - ARC, as defined by Department of Public Health rules (1989 Public act 174), third party Information. I understand that I may revoke this authorization at any time by notifying Sunrise Medical Associates in writing, otherwise, it will remain in effect for a period of 12 months from the date signed. This authorization pertains to fulfillment of the above stated purpose(s). Covered entity will not condition treatment, payment, enrollment or eligibility. I understand that information disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer protected by HIPAA's privacy rule protections.
I have read the above, and acknowledge that I am familiar with and fully understand the terms and condition of this authorization.