I understand the information in my health records may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.
This information my be disclosed and used by:
Dr. Alamain Karim
Sleep Health Partners LLC
9370 SW Greenburg Rd. Suite #422, Porland OR 97223
Phone: 503-716-6712 Fax: 971-339-0824 Email: firstname.lastname@example.org
I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to the information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will not expire.
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I understand that without the requested information, medical billing may not be possible. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confiedntiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure.
I have read the above forgoing authorization for Medical Records Release of Information and do hereby acknowledge that I am familiar wit hand fully understand the terms and conditions of this authorization.