If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use and disclosure of the information may apply. I understand and agree that this information will be disclosed if I check the applicable space next to the type of information.
I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer be protected under federal law. However, I also understand that federal or state law may restrict re-disclosure of HIV/AIDS, mental health, genetic testing and drug/alcohol diagnosis, treatment, or referral information. You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect the ability to receive health care services or reimbursement for services. The only circumstance when refusal to sign means you will not receive health care services of if the service are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure. You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may no longer be used for the purpose described in this written authorization. Any use or disclosure already made with your permission cannot be undone. (physician/entity (contact person) at To revoke this authorization, please send a written statement to disclosing information) and state that you are revoking the authorization. I have read and understand this authorization. Unless revoked, this will expire in 180 days.