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HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

I. THE PATIENT
II. AUTHORIZATION
Authorization Options*
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III. DISCLOSURE

Individual/Organization Authorized by Signatory to Disclose and Receive Personal Health Information:

IV. PURPOSE
Purpose Options*
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Termination
This authorization will terminate: (check one)*
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I understand that I have the right to revoke this authorization, in writing and at any time, except where uses or disclosures have already been made based upon my original permission. I might not be able to revoke this authorization if its purpose was to obtain insurance.

I understand that uses and disclosures already made based upon my original permission cannot be taken back.

I understand that it is possible that Medical Records and information used or disclosed with my permission may be re-disclosed by a recipient and no longer protected by the HIPAA Privacy Standards.

I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create Medical Records for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.

I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.
Signature Section

ADDITIONAL CONSENT FOR CERTAIN CONDITIONS

Sensitive Information
This medical record may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment. Separate consent must be given before this information can be released.
Consent
HIV/AIDS Information
This medical record may contain information concerning HIV testing and/or AIDS diagnosis or treatment. Separate consent must be given to have this information released.
Consent*
Please select at least one option

Thank you for taking the time to fill out this form.