Hipaa Release And Authorization Form Page 2

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RELEASE
4.
Each covered entity that acts in reliance on this Release shall be released from liability which may result from disclosing my individually
identifiable health information and other medical records.
LEGAL ACTION
5.
I authorize my agent to bring a legal action against a covered entity which refuses to accept and recognize this Release. Further, in
order to fulfill my intent as expressed herein, I authorize my agent to sign any documentation that my agent deems necessary or
appropriate in order to secure the disclosure of my individually identifiable health information and other medical records.
6.
SUBSEQUENT DISCLOSURE OF INFORMATION
Any information disclosed to my agent pursuant to this Release may subsequently be disclosed to another party by my agent. My
agent shall not be required to indemnify a covered entity or perform any act in the event information is subsequently disclosed by my
agent.
7.
COPIES AND FACSIMILES
Copies or facsimiles of this Release shall be as valid as the original Release.
8.
EXECUTION
I sign my name to this Release on _________________________, 20___,
at ________________________________________________
(City, County, State)
________________________________________
Principal
SIGNATURE OF FIRST WITNESS
Witness Signature: __________________________________________
Print Name: __________________________________________
Address: __________________________________________
Date: ______________________________, 20___
SIGNATURE OF SECOND WITNESS
Witness Signature: __________________________________________
Print Name: __________________________________________
Address: __________________________________________
Date: ______________________________, 20___
Notary Certificate (Optional)
State of Colorado
County of _______________
The foregoing instrument was acknowledged before me this _____ day of __________, 20____,
by ________________________________________, Principal.
_________________________
_____________________
(Notary Seal)
Notary Public Signature
My commission expires:

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