• Patient Authorization for Use and Disclosure of Protected Health Information

  • This authorization permits New Path Medical Center to use and/or disclose the following individually indentifiable health information about me (specifically describe the information to be used or disclosed, such as date(s) of service, type of services, level of detail to be released, origin of information, etc. 

  • I do not have to sign this authorization in order to receive treatment from New Path Medical Center. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the privacy office at:

    New Path Medical Center, PO Box 1780, Columbia, KY 42728

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  • Patient/guardian must be provided with a signed copy of this authorization form.

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