- I release the entities listed above, their agents and employees from any liability in connection with the use or disclosure of the protected health
information. The entity authorized to disclose the information will not be compensated by the recipient for such disclosure. Normal applicable fees, such
as copy fees, may apply.
- Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal law.
However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.
- Unless the purpose of this authorization is to determine payment of a claim for benefits, the requesting entity will not condition the provision of
treatment, payment, enrollment in a health plan, or eligibility for benefits on obtaining this authorization.
I understand that the information authorized for use or disclosure may include information which may indicate the presence of a communicable or
non-communicable disease and may include, but is not limited to, diseases such as hepatitis, syphilis, gonorrhea, and human immunodeficiency viruses
also known as Acquired immune Deficiency Syndrome (AIDS). I further understand that my medical information may indicate that I have or have been
treated for psychological or psychiatric conditions or substance abuse.