The purpose for the use/disclosure of this information is hospital publicity or public education.
I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the revocation to the DCH Health Information Management Department (Medical Records). I understand that revocation will not apply to information that has already been released in response to this authorization. Unless otherwise revoked, this authorization for use will expire six (6) years from the date of submission.
I understand that authorizing the disclosure of health information is voluntary. I can refuse to sign this authorization. I need not sign this authorization in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided by 45CFR 164.52-54. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by the federal confidentiality rules.