Patient Authorization for Disclosure

Patient Authorization for Disclosure of PHI. I hereby authorize the use and/or disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary and that I may refuse to sign this authorization. My treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization, unless the authorization is for the purpose of creating PHI for disclosure to a third party. I understand that I may revoke this authorization at any time by submitting a written revocation, except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations. This authorization shall expire on [Date] or upon [Event], whichever occurs first. If no expiration date or event is specified, this authorization shall expire twelve (12) months from the date signed.