Authorization to use or disclose protected health information
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District of Columbia
Date of request
As required by the Privacy Regulations, this practice may not use or disclose your protected health information except as provided in our Notice of Privacy Practices without your authorization.
I hereby authorize this office and any of its employees to use or disclose my Patient Health Information to the following person(s), entity(s), or business associates of this office:
Patient Health Information authorized to be disclosed:
For the specific purpose of (describe in detail):
Effective dates for this authorization, from:
This authorization will expire at the end of the above period. I understand that the information disclosed above may be re-disclosed to additional parties and no longer protected for reasons beyond your control.
I understand I have the right to revoke this authorization by sending written notice to this office and that revocation will not affect this office’s previous reliance on the uses or disclosure pursuant to this authorization. I also have the right to refuse to sign this authorization, to receive a copy of this authorization and to restrict what is disclosed with this authorization.
I also understand that if I do not sign this document, it will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits whether or not I provide authorization to use or disclose protected Patient Health Information.
Signature of Patient or Patient’s Authorized Representative
Authorized Signature of Facility