The purpose of this authorization is to meet the patient's request for information disclosures and uses.
Expiration date or event:
The authorization shall be enforce until revoked by the patient or
Verification method or code:
This practice will verify the identify of any entity requesting protected health information. Verification information may include:
Rights of the Patient
I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.
I understand that I have the right to revoke this authorization at any time by sending a written notification to the address listed at the top of this form. I understand that a revocation is not effective in cases where the information has already been used or disclosed but will be effective going forward.
I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Office Use Only:
Your information will be encrypted.
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