Digestive Medicine Associates
2140 West 68th Street, Suite 305 Hialeah, FL 33016-1815
Ph: (305) 822-4107
Fax: (305) 822-5086
This authorization shall be in force effect from the date signed below until (specify date) or (event that relates to the patient or the purpose of the use or disclosure) at which time this Authorization to use or disclose this protected health information exprires.
I understand that I have the right to revoke this Authorization, in writing, at any time by sending such written notification to Privacy Office at 2140 W 68th St, Suite 305, Hialeah, FL 33016. I understand that a revocation is not effective to the extent that Digestive Medicine Associates has relied on the use or disclosure of the protected health information.
I understand that information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
I understand that I have the right to:
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