Methods of Disclosure Authorized: Faxed, written, phone conversation, in-person and/or secure e-mail.
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I understand that I may revoke (withdraw) this authorization at any time by notifying the practice in writing. Revocation will be effective as of date received.
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I understand that a revocation will not apply to: 1)any actions that this practice has already taken while relying on this authorization
before I revoke it; or 2)
if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right
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I understand that I might be denied services if I refuse to consent to disclosure for purposes
of treatment, payment, or health care
operations
, if permitted by state law. I will not be denied services if I refuse to consent to disclosure for other purposes.
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I
understand that the recipient of some information disclosed under this authorization may re-disclose this information and that the
information will no longer be protected by federal privacy regulations.
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I understand that I have the right to: 1) Inspect or copy the protected heath information to be used or disclosed as permitted under
Federal law; 2) Refuse to sign this authorization.
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This authorization will remain in effect for one year and may be revoked at any time by notifying this practice in writing.
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Unless otherwise noted, only the past two years of electronic records as stipulated above will be sent.