I understand that:
➔The information in my health record may include information relating to ecually transmitted
deseases, 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 or drug abuse.
➔I have a right to revoke this authorization at any time. If I revoke this authorization, I must do so in
writing. This authorization shall remain valid unless revoked but will expire 1 year after signing.
➔Revocation will not apply to information that has already been released in response to this
➔Once the above authorization is disclosed, there is a possibility that it may be re-disclosed by the
recipient, and therefore may not be protected by the federal privacy law regulations.
➔Failure to provide all required information will not constitute a proper authorization to disclose
protected health information and that; therefore, my request may not be honored.
➔Authorization to use or disclosure of the information identified above is voluntary. I need not sign
this form to ensure healthcare treatment. Pay or eligibility for benefit