Note: if checkbox is not slelected, the last 6 months will be copied/printed.
THERE MAY BE A CHARGE FOR PROVIDING COPIES.
Protected or Sensitive Information
If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use
and disclosure of the information may apply. I understand and agree that this information will be disclosed if I place my initials in the
applicable space next to the type of information.
HIV / AIDS information
Mental health information
Initials
Initials
Drug / Alcohol diagnosis, treatment or referral information
Genetic Testing information
Initials
Initials
I understand that the information used or disclosed pursuant to the authorization may be subject to re-disclosure and no longer
protected under federal law; however, I also understand that federal or state law may restrict re-disclosure of HIV/AIDS information,
mental health information, genetic testing information and drug/alcohol diagnosis, treatment or referral.
You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health
care services or reimbursement services. The only circumstance when refusal to sign means you will not receive health care services 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.
You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may no
longer be used or disclosed for the purpose in this written authorization. Any use or disclosure already made with your permission
cannot be undone. To revoke this authorization, please send a written statement to our clinic addressed to Medical Records. Unless
revoked, this authorization expires one year from date below.
Signature of Patient or Patient's Legal Representative
Date
Print Patient’s Name or Name of Patient’s Legal Representative
