* I may revoke this authorization at any time in writing, although such a revocation will not apply to information already used or disclosed in response to this authorization. Please refer to the Optometric Associates Notice of Privacy Practices for additional information regarding revocation and disclosure of Protected Health Information (PHI);
* Information used or disclosed pursuant to this authorization my be subject to re-disclosure by the recpient and no longer protected by federal law. However, the recipient may be prohibited from disclosing sustance abuse information under the Federal Substance Abuse Confidentiality Requirements;
* I understand and acknowledge that this authorization extends to use and/or disclose from my medical record, which may include treatment for physical and mental illness, alcohol and/or drug abuse, and/or AIDS, and/or my include results of an HIV test or the fact that an HIV test was performed;
* Optometric Associates will not condition the provision of treatment, payment, enrollment, or eligibility for benefits based on the execution of the authorization.
* Any requests for paper recreation of the medical records and/or other documents that are currently owned and protected by Optometric Associates including but not limited to colored printing of and recreation of medical documents will result in additional charges to the requesting party. Charges for paper recreation of medical records are governed by applicable laws of the State of Pennsylvania.
* This authorization for release of PHI data will expire in one (1) calendar year after the date on this request.