Terms of Authorization
I understand that once the Covered Entity (Medical Provider) discloses
my health information to the recipient, the Covered Entity and its
affiliates cannot guarantee that the recipient will not redisclose
my health information to a third party. The third party may not be required to abide by this Authorization or applicable law governing the use and disclosure of my health information.
I understand that I may at any time make a written request to the Covered Entity and its affiliates to inspect and/or obtain a copy of my health information, and that the Covered Entity and its affiliates will either, within five days for a request to inspect and fifteen days for a request to copy, grant the request and contact me to arrange for a convenient time to inspect and/or copy my health information or provide me with a written denial of the request that states the basis for the denial, my review rights (if any), and instructions as to how and to whom I may register a complaint regarding the denial.
I understand that I may refuse to sign or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of my treatment; except, however, if my treatment is for the sole purpose of creating health information for disclosure to the recipient identified in this Authorization, in which case the Covered Entity and its affiliates may refuse to treat me if I do not sign this Authorization.
I understand that this Authorization will remain in effect until the term of this Authorization expires or I provide a written notice of revocation to the Covered Entity’s Privacy Office. The revocation will be effective immediately upon the Covered Entity's receipt of my written notice, except that the revocation will not have any effect on any action taken by the Covered Entity in reliance on this Authorization before it received my written notice of revocation.
I have read and understand the terms of this Authorization. By my signature below, I hereby, knowingly and voluntarily, authorize the Covered Entity to use or disclose my health information in the manner described above.