You're almost done. You must sign the form or it WILL NOT be submitted.
Health Information sent in an unencrypted email is not secure. The Health Information may be intercepted and seen by others. There are other risks with an unencrypted email including misaddressed or misdirected messages, email accounts that are shared, messages forwarded to others, and messages that are stored on servers that have no security. By choosing to receive your Health Information by unencrypted email, you are acknowledging and accepting these risks. Your name, home address, insurance information, medical information, and other personal information may appear on the records we are sending to you.
- This Authorization is valid for one year from the date that I signed unless another date is listed below.
- This Authorization is voluntary. My treatment will not be impacted even if I do not sign this Authorization.
- My Health Information may include information about behavioral or mental health services, treatment for alcohol and drug abuse.
- I may revoke or withdraw this Authorization, except to the extent that action has been taken prior to the receipt of the revocation or withdrawal, by mailing or faxing my written request along with a copy of the original Authorization to the department where my Authorization was made or given.
- The information to be released maybe from my electronic health record (EHR). I understand that the data from the EHR are current as of the date printed. I further understand that in reducing the data to paper, information from the electronic database is being reformatted onto paper and the page numbers may reflect the printed document, not actual pages in the EHR.
- Once my Health Information is disclosed as requested, it may no longer be protected by federal or state privacy laws and could be re-disclosed by the person(s) receiving it.
- If I am not making this request in person, I may be asked to provide a copy of my current driver’s license or state identification.
- This release is being made at my request.