Disclosure of Protected Health Information
I agree to the Protected Health Information Policy outlined below.
Expiration Date of Authorization
I understand that there is no expiration of this authorization. However, this authorization can be terminated at any time at the written request of the patient.
Right to Terminate or Revoke Authorization
I understand that I may revoke this authorization by submitting a written revocation to Pediatric People’s Director of Administration.
Potential for Subsequent Disclosure
I understand that the information that is disclosed under this authorization may be disclosed again by the person or organization to which it was sent. The privacy of this information may not be protected under the federal privacy regulation.