Methods of Disclosure Authorized: Faxed, written, phone conversation, in-person and/or secure e-mail.
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.
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
I understand that I might be denied services if I refuse to consent to disclosure for purposes
of treatment, payment, or health care
, if permitted by state law. I will not be denied services if I refuse to consent to disclosure for other purposes.
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.
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.
This authorization will remain in effect for one year and may be revoked at any time by notifying this practice in writing.
Unless otherwise noted, only the past two years of electronic records as stipulated above will be sent.