Authorization to Disclose Health Information


Please correct the errors described below.

I hereby authorize the use or disclosure of information from the medical records of

Release of Information from Waco Gastroenterology Associates, PA

I understand that the information released is for the specific purpose stated above. Any other use of this information without written consent of the patient is prohibited.

I understand that I have the right to revoke this authorization at any time by presenting a written request to the individual or organization releasing the info. I understand that the revocation will not apply to information already released in response to this authorization and will not apply to my insurance company when the law allows my insurance access to my information. Unless otherwise revoked

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign the authorization and need not sign in order to ensure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure. I f have questions about the disclosure of my health information, I can contact a representative or the individual or the organization above.

I understand that my medical record may contain reports, test results, and notes that only a physician can interpret. I understand and am herby advised that I should contact my physician regarding the entries made in my medical record to prevent my misunderstanding of the information contained in these entries. I will NOT hold Waco Gastroenterology Associates, PA liable for any misinterpretation of the information in my medical record as a result of not consulting my physician for the correct interpretation.

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