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HIPAA Authorization

 

1.AUTHORIZED PERSONS TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

My insurance provider is authorized to disclose the following protected health information to Premier Mastectomy Vendor of Montgomery, Alabama 36117.

 

2. DESCRIPTION OF INFORMATION TO BE DISCLOSED

The health information that may be disclosed is all past, present, and future periods of health care information may be shared.

 

3. PURPOSE OF THE USE OR DISCLOSURE

The purpose of this use or disclosure is so that Premier Mastectomy Vendor can provide services to me.

 

4. VALIDITY OF AUTHORIZATION FORM

This Authorization Form is valid beginning on January 01, 2024 and expires upon termination of services.

 

5. ACKNOWLEDGMENT•

  • I understand that the information used or disclosed under this Authorization Form may be subject to redisclosure by the person(s) or facility receiving it and would then no longer be protected by federal privacy regulations.

  • I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization.

  • I have the right to refuse to sign this Authorization Form.

  • If signed, I have the right to revoke this authorization, in writing, at any time.

  • I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

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