This is to certify that I, the undersigned patient (or person legally authorized to act for the patient), have read this Authorization for Use or Disclosure of Protected Health Information and give this agency making the authority to use or disclose the information on the basis described in this Authorization.

I, the undersigned patient (or person legally authorized to act for the patient), understand that

• Except for the reasons described in the Notice of Privacy Practices, I, the undersigned patient (or person legally authorized to act for the patient), may revoke this Authorization in writing at any time following the information in the Notice. [45 CFR 164]
• Unless the Authorization is for one of the purposes described below, the patient's treatment, payment, enrollment in a health plan or eligibility for benefits may not be conditioned on my agreement (or the agreement from person legally authorized to act for the patient) to sign this.
  • I, the undersigned patient (or person legally authorized to act for the patient), understand that, if this Authorization is for research-related treatment, this may be conditioned on my agreement (or the agreement person legally authorized to act for the patient) to sign this.
  • I, the undersigned patient (or person legally authorized to act for the patient), understand that, if this Authorization is solely for the purpose of creating protected health information for disclosure to the person or organization described below, the provision of health care for this purpose may be conditioned on my agreement, as the undersigned patient (or person legally authorized to act for the patient), to sign this Authorization.
• The information authorized to be used or disclosed following this Authorization may be subject to re-disclosure by the person or organization receiving it and no longer protected by federal privacy regulations.