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The information used or disclosed in this authorization may be subject to redisclosure and may no longer be protected under federal law. Refusal to sign this authorization will not affect the patient’s ability to obtain health care services or reimbursement for services unless authorization is required to bill the patient’s insurance company. Patient Info

Healthcare Provider to Release Information:

Person or Agency to Receive Information:

Federal or state law may restrict redisclosure of HIV-positive test results and HIV diagnosis, other sexually transmitted disease information, specially protected mental health information, genetic testing information, and drug/alcohol diagnosis treatment or referral information. The person or entity I am authorizing to use and/or disclose the information may receive compensation for doing so. The only circumstance when refusal to sign means the patient will not receive health care services is if the health care services are solely for the purpose of providing health information to someone else, and the authorization is necessary to make that disclosure. My refusal to sign this authorization will not adversely affect my enrollment in a health plan or eligibility for health benefits unless the authorized information is necessary to determine if I am eligible to enroll in the health plan.

I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance upon this authorization. If I revoke my authorization, the information described above may no longer be used or disclosed for the purpose described in this authorization. Unless revoked earlier, this authorization will expire on the earlier of 1 year from the date of signing or on

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