Authorization for Release of Health Information

If we, the healthcare provider, are requesting this Authorization from you for our own use and disclosure or to allow another healthcare provider or health plan to disclose information to us:

• We cannot condition our provision of services or treatment to you on the receipt of this signed authorization;
• You may inspect a copy of the protected health information to be used or disclosed;
• You may refuse to sign this Authorization; and
• We must provide you with a copy of the signed Authorization.

You have the right to revoke this Authorization at any time, provided that you do so in writing, and except to the extent that we have already used or disclosed the information in reliance on this Authorization or to the extent you signed this Authorization as a condition to insurance coverage. To revoke this Authorization, please contact our Privacy Officer.

I hereby consent and authorize Journey Family Medicine to: (Initial each statement)

I have reviewed and I understand this Authorization. I also understand that the information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer be protected under federal law. Unless revoked earlier, this Authorization shall remain in effect for 12 months or until age 13, whichever comes first.