I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment or enrollment). However, I do have to sign an authorization form:
• To take part in a research study, or
• To receive health care when the purpose is to create health information for a third party.

I may revoke this authorization in writing. If I do, it will not affect any actions already taken by the above named practice based upon this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. Two ways to revoke this authorization are:
• Fill out a revocation form. The form is available from the office, or
• Write a letter to the office.
Once the office discloses health information, the person or organization who receives it may re-disclose it.
Privacy laws may no longer protect it.

Records Release

Authorization to Use and Disclose Health Information