I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it, and that in any event this authorization expires automatically as follows: one (1) year after the patient’s dated signature (below). Revocations should be submitted to the health information department, where the information and appropriate revocation forms are kept.
I understand that my records are currently protected by Oklahoma State Statutes and federal privacy regulations, including the Health Insurance Portability and Accountability Act (HIPAA), 45 CFR Parts 160 & 164. I understand that my health information specified above will be discussed pursuant to this authorization, and that the recipient of the information may redisclose the information, and it may no longer be protected by the HIPAA privacy law. When applicable, the federal regulations governing the confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, prohibit redisclosure of such information without my specific written consent or when permitted by such regulations.
I understand that the covered entity and/or program seeking this authorization will not condition treatment, payment enrollment, or eligibility for benefits on whether I sign this authorization. I freely and voluntarily give this consent.
I understand that I am entitled to receive a copy of this authorization after it is signed.
THE INFORMATION AUTHORIZED FOR RELEASE MAY INCLUDE RECORDS WHICH MAY INDICATE THE PRESENCE OF A COMMUNICABLE OR NON-COMMUNICABLE DISEASE.
