I understand that there may be sensitive information contained in my medical record for which I give my authorization to release: My signature on this form knowledges that my records may contain the information below and authorizes the release of such information.
- Sexually Transmitted Diseases (HIV/AIDS/Other)
- Genetic Inforamtion
- Mental Health/Biobehavioral
Notice: Any disclosure of information has the potential for further release or distribution by the recipient that may not be protected by confidentiality laws.
My Rights: I understand that:
- This authorization is voluntary. Treatment, payment, enrollment, or eligibility for beneifts may not be conditioned on signing this authorization.
- I may revoke this authorization at any time, with some expectations, by informatng Phoenix Unified Surgeons in writing. The revocation will take effect once received.
- I understand that once the information has been released to the recipient according to the terms of this authorization, the information may be re-disclosed.
Expiration of Authorization: This authorization expires six (6) months from date signed.
