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555 S 10th St, Suite 107
Lincon, NE 68508
(Facility/Provider Name and Location)
Re-disclosure of Information - I understand that once information is disclosed pursuant to this authorization that the Health Insurance
Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164, protecting health information may not apply to the
recipient of the information and, therefore, may not prohibit the recipient from re-disclosing it. Alcohol and/or drug treatment records are
protected under the federal regulations governing Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the recipient must be
informed that re-disclosure is prohibited except as permitted or required by law.
Right to Refuse to Sign this Authorization - I understand that generally the person(s) and/or organization(s) listed above who I am
authorizing to use and/or disclose my Information may not condition my treatment, payment or eligibility for health care benefits on my
decision to sign this authorization.
Right to Revoke - I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in
reliance on it.
Right to Inspect - I understand that I have the right to inspect or copy the health information I have authorized to be used or disclosed by
this authorization form.
Expiration Date - I understand that unless revoked, this authorization expires in 180 days from the date it is signed or upon
the date listed below, whichever is sooner.
(date or event relate to the purpose of authorization)
I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming
that it accurately reflects my wishes.
By checking the "I agree" box below, you agree and acknowledge that 1) your document will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
This field is not part of the form submission.
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