Authorization for Disclosure of Medical Information

I understand that this authorization is voluntary. I need not sign this form in order to ensure treatment, enrollment or eligibility of health
benefits or payment for services rendered to me. I may inspect or copy the information to be used and/or disclosed.
2. I understand that if the organization/individual receiving the information is NOT a health plan or health care provider, the released information might no longer be protected by Federal privacy laws and might be re-disclosed by the recipient without my authorization.
3. I understand that I have a right to revoke this authorization in writing at any time unless it has already been acted on, and that such revocation will not affect my treatment, enrollment or eligibility of health benefits or payment for services rendered to me.
4. This authorization is valid for 1 year from the date of signing unless it has been revoked.
5. Insurance applicants: withholding or release of information may be governed by your insurance company’s regulations, state law, and/or
federal law.
6. I knowingly and voluntarily authorize the above provider to disclose and/or use the health information specified in the manner described above.