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  • Authorization for Use and Disclosure of Health Information

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  • 2. I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that this is voluntary. I understandthat after the above-named facility discloses this information, it no longer has control over protection of the confidentiality of the information. Should the recipient re-disclose the information, it will no longer be protected by the Federal Privacy Regulations.

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  • If mailing, where do you want the information sent? (fill in boxes below):

  • 5. I understand that the information in my health record may include information relating to: Sexually transmitted diseases                     Human immunodeficiency syndrome (HIV)  Behavioral or mental health services     Acquired immunodeficiency syndrome (AIDS)

    Treatment for alcohol and drug abuse - protected by Federal Regulation 43 CRF part 2

  • 6.  This information may be disclosed to and used by the following individual or organization:

  • 7. I understand that I have a right to 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 appropriate Delta Health System facility. I understand that the revocation will not apply to information. that has already been released in response to this authorization. Unless otherwise revoked, this authorization will expire on the following date, event, or condition:

  • If I fail to specify an expiration date, event, or condition, this authorization will expire in one year.

  • 8. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in 45 CFR §164.524. I understand that any disclosure of information carries with it the potential for unauthorized disclosure access, and the information may not be protected by the federal confidentiality rules. If I have question about disclosure of my health information, I can contact the Health Information Department at the appropriate Delta Health System facility or the System Privacy Officer at 662-725- 2264.

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