18 Year Old Authorization
Patient Authorization for Release of Medical Information

Description of the specific information to be used or disclosed:(Please check one of the following:)

I understand that:

  • I may inspect or copy the protected health information to be used or disclosed.
  • I may revoke this authorization in writing by contacting your office at the address above, attention Privacy Officer.
  • Information used or disclosed pursuant to the Authorization may be subject to re-disclosure by the recipient and no longer protected by HIPAA.