I do hereby consent to and authorize to disclose health information about me and that can be identified with me from my records relating to my identity, diagnoses, prognosis, and/or treatment, which records may include information related to medical conditions, tests, mental or behavioral health, and substance abuse (drug and alcohol), and HIV-related. These records are called protected health information and are protected by federal and/or state law.
I understand that this authorization is revocable except to the extent that action has been taken in reliance thereon and that this consent will remain in force unless revocation from the patient or legal guardian is received. I also understand that any revocation of this authorization must be in writing and sent or delivered to health care provider’s office. I also understand that my decision to revoke this authorization may result in my insurance company not being able to pay for my medical care and I will be liable for payment for the services rendered.
