I understand as the patient or person authorized to act on the patient’s behalf the following applies;
· I am entitled to receive a copy of this authorization, and the requester may be provided a copy of this authorization.
· I am entitled to inspect my records and that a reasonable fee may be charged for the records.
· I may revoke this authorization in writing at any time, except to the extent that release has been made prior to my revocation in reliance on this authorization and that such release shall not constitute a breach of my right to confidentiality.
· I understand that Clearview Dermatology, LLC does not, and cannot control how a recipient uses or shares any information provided to the recipient in accordance with the authorization and that the recipient may not be bound by the same obligations as Clearview Dermatology, LLC
· I understand that my treatment, and receipt of services at Clearview Dermatology, LLC will not be affected by signing this form, or refusal to sign this form.
I hereby release Clearview Dermatology, LLC (and subsidiaries), its professionals, employees and agents from all liability arising from this authorized disclosure of my health information. Unless otherwise revoked, this authorization will remain in effect from the of this Authorization for one year, unless otherwise indicated. I understand there may be a fee involved for the reproduction of the requested health information. The fee charged, as allowed by applicable Massachusetts law, may vary depending on the number of pages being copied.