Above listed patient authorizes the following healthcare facility to make record disclosure:
RESTRICTIONS: Only medical records from this healthcare facility will be copied unless requested. This authorization is valid only for the release of medical information dated before and including the date on this authorization unless other dates are specified
I understand the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse
This information may be disclosed and used by the following individual or organization:
Release To: Vida Clinical Research 102 Park Place Blvd Suit B-2 Kissimmee FL 34741 Phone: 407-750-5300 Fax: 407-935-0095
I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law gives my insurer the right to consent to a claim under my policy.
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need to sign this form to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for unauthorized redisclosure, and the information may not be protected by federal confidentiality rules. If I have questions about the disclosure of my health information. I can contact the authorized individual or organization making the disclosure.
