Authorization For The Release Of Protected Health Information Form (Page 2 of 2) in pdf

RIGHT TO REVOKE AUTHORIZATION

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing

and present my written revocation to the physician’s office indicated above. I understand that the revocation will not apply to any health

information that has already been released in response to this authorization.

RE-DISCLOSURE

I understand that if my health information is disclosed to a party other than a health care provider, health plan or health care clearinghouse

subject to the federal privacy regulations, my health information disclosed pursuant to this authorization may no longer be protected by the

federal privacy regulations.

FEES

I understand that federal and state laws allow a fee to be charged for copying patient records and I will be responsible for the payment of such

fees, if any are applied. It is Harbin Clinic’s policy not to charge patients for copies of their medical records.

REFUSAL TO AUTHORIZE USE AND/OR DISCLOSURE

If I have been asked to sign this form in order to authorize the disclosure of my health information for purposes related to worker’s

compensation I understand that Harbin Clinic may decline to treat me if I refuse to sign this authorization only if: the treatment would be for the

sole purpose of creating health information for disclosure to a third party (such as a workers compensation examination).

RELEASE AND WAIVER

If the health information that I have requested to disclose contains any privileged psychiatric or psychological information related to the

treatment of physical and/or mental illness, chemical dependency or alcohol abuse, or testing or treatment of any communicable or infectious

disease such as acquired immunodeficiency syndrome (AIDS), Immunodeficiency Syndrome Related Complex (ARC), human immunodeficiency

virus (HIV), Venereal Disease, Tuberculosis, or Hepatitis, I hereby waive any privilege concerning such information for the purpose(s) of releasing

it to the party or parties authorized above. I also release Harbin Clinic, and their officers, managers, agents and employees from any and all

liabilities, damages and claims, which might arise from the release of the above health information.

Signature of Patient (or Patient’s LEGAL Representative) _______________________________________ Date ______________

Description of Authority to Act for Patient _________________________________________

Authorization For The Release Of Protected Health Information Form Page 2