This authorization expires in six (6) months from the date signed or earlier
TO BE READ AND SIGNED BY PATIENT:
I understand the following:
I may revoke this authorization at any time by providing written notice to the practice
I may not be able to revoke this authorization if the practice has already taken action utilizing this authorization, or if the authorization was obtained as a condition of obtaining insurance coverage.
The practice will not condition treatment or payment based on my signing this authorization.
I am signing this authorization freely and under no pressure from any individual to do so
The information disclosed in this authorization may be subject to re-disclosure by the practice and no longer protected by federal law
I acknowledge that I have had an opportunity to review this authorization and understand the intent and use
This authorization my include disclosure of information relating to ALCOHOL and DRUG ABUSE and CONFIDENTIAL HIV RELATED INFORMATION only if I place my initials on the appropriate box above.
If I am authorizing the release of HIV related, alcohol or drug treatment information, the recipient is prohibited from re-disclosing such information without my authorization unless permitted to do so under federal and state law. I understand that I have the right to request a list of people who may receive or use my HIV related information without authorization. If I experience discrimination because of disclosure of HIV related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.