I understand and agree that:
-
This authorization is voluntary;
-
My health information
may contain information
created by
other persons
or
entities including health care providers and may
contain
medical, pharmacy,
dental, vision, mental
health,
substance abuse, HIV/AIDS, psychotherapy,
reproductive,
communicable disease and health
care program information;
-
I may not be denied treatment,
payment for health care services,
or enrollment
or
eligibility
for health
care benefits if I
do not
sign this form except
(1) if my
treatment
is related to
research,
or (2) health care services are provided
to
me
solely for the
purpose of creating protected health information
for disclosure to
a
third party
;
-
My health information
may be subject
to
re-disclosure by
the recipient,
and if the
recipient is not
a health plan or health care provider,
the information
may no
longer be protected by
the federal
privacy regulations;
-
I understand that I have a
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 Specialty Natural Medicine. I understand that
the
revocation
will not apply to information that
has already
been released in
response to
this
authorization.
I understand that
the revocation
will not apply to
my insurance
company when the law
provides my
insurer with
the right
to contest
a claim under
my policy.
-
I agree that my signature on this document (hereafter referred to as my "E-
Signature") is as valid as if I signed the document in writing. I also agree that no
certification authority or other third party verification is necessary to validate my E-
Signature, and that the lack of such certification or third party verification will not in
any way affect the enforceability of my E-Signature or any resulting agreement
between Specialty Natural Medicine, Inc PC. and me.
This authorization is voluntary;
By signing this page, I acknowledge that I have read and agree to the terms on both sides of this form.