• Authorization for Release of Information

    Authorization for Release of Information

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  • I understand the following:

    *This authorization will expire 1 YEAR from the date this form is signed.

    *I may revoke this authorization at any time by notifying the providing organization in writing.

    *My notification will be effect on the day it is received, unless action has already been taken on the original request.

    *The information used before this authorization may subject to redisclosure by the recipient and no longer protected by federal privacy regulations.

    ACKNOWLEDGEMENT:  I have had the opportunity to review the contents of this authorization. By signing below, I am certifying my agreement with the statements made in this form and agreeing to the release of my protected health information as indicated on this form.

     

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