Entity to Receive Information
Check each person/entity that you approve to receive information.
Description of information to be released.
Check each that can be given to person/entity.
- I have the right to revoke this authorization at anytime.
- I may inspect or copy the protected health information to be disclosed as described
in this document.
- Revocation is not effective in cases where the information has already been
disclosed but will be effective going forward.
- Information used or disclosed as a result of this authorization may be subject to
redisclosure by the recipient and may no longer be protected by federal or state
- I have the right to refuse to sign this authorization and that my treatment will not
be conditioned on signing.