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  • Authorization for Release of Patient Health Care Information

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  • I hearby authorize release of medical records and discussion of my care BETWEEN:

    GREENLAKE PSYCHIATRIC CARE

    AND

  • I understand that I may inspect or copy the protected health information to be disclosed, that I may revoke this authorization in writing by contacting either of the above offices, and that information disclosed pursuant to this authorization my be subject to re-disclosure by the recipient and may no longer be protected by HIPPA.

    I understand I may refuse to sign this authorization and that you will not condition treatment, payment or enrollment. However, I do need to sign to take part in a research study, for research-related treatment and to receive health care when the purpose is to create health care information for a third party.

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  • Confidential Heath Information Fax

    This message is intended only for the person listed above. If the reader of this fax is not the intended recipient or this transmission is received in error, please notify us and shred this information. Thank you for your assistance.

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