I understand that information to be released may include reference to sensitive information related to mental and behavioral health, HIV/AIDS or other communicable diseases, and drug or alcohol use.
I understand that I have the right to revoke this authorization at any time except to the extent that action has been already completed based on this authorization.
This release is valid for 1 year from the date of execution unless revoked in writing.
To revoke this authorization, I must submit a written revocation to the HIM department at Terros Health.
I understand that my healthcare cannot be based on this authorization unless the purpose is solely to obtain and disclose information to a third party, such as an employer. I understand that this authorization is voluntary, and I will not be denied treatment if I refuse to sign this authorization, and that I may request a copy.
I understand that the information disclosed by Terros Health with this authorization may be re-disclosed by the entity that receives this information and may no longer be protected by privacy regulations.
I authorize Terros Health to disclose and/or receive medical information regarding my treatment to include any protected health information to/from the entity as indicated on this authorization form.