1. I understand that I do not have to sign this authorization in order to get health care benefits (treatment, payment, enrollment, or eligibility for benefits). However, I do have to sign an authorization form:
- to receive research-related treatment in connection with research studies or
- to receive health care when the purpose is to create health care information for a third party.
2. I may revoke this authorization in writing at any time. If I do, it will not affect any action taken by Richmond Pediatrics in reliance on this authorization before it receives my written revocation. I may not able to revoke this authorization if its purpose was to obtain insurance. Two ways to revoke this authorization are:
- Fill out a revocation form - a form is available from Richmond Pediatrics or
- Write a letter to Richmond Pediatrics
3. Protection after Disclosure. I understand that once my health care information is disclosed, the person or organization that receives it may re-disclose it and that privacy laws may no longer protect it.