Please read the information below before proceeding:
I understand the information in my health record may include information relating to sexually transmitted
disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also
include information about behavioral or mental health services, and treatment for alcohol and drug abuse.
I understand once the information below is released, it may be re-disclosed by the recipient and the information
may not be protected by federal privacy laws or regulations.
I understand I have a right to revoke this authorization at any time. I understand if I revoke this authorization,
I must do so in writing and present my written revocation to the practice. I understand the revocation will
not apply to information that has already been released in response to this authorization. I understand the
revocation will not apply to my insurance company when the law provides my insurer with the right to contest
a claim under my policy.
I understand authorizing the use or release of this information is voluntary. I need not sign this form to ensure
health care treatment.
