I understand that the disclosed information may be re-disclosed in accordance with law and may no longer be protected by the federal privacy standards. Further, I understand that if the authorized recipient is not a provider, health plan, or clearinghouse required to comply with federal privacy standards, the information disclosed pursuant to this authorization may no longer be protected by the federal privacy standards. However, other state or federal law may prohibit the recipient from disclosing specially protected information, such as substance abuse treatment information, HIV/AIDS-related information, and psychiatric/mental health information.
I understand there may be a charge of up to $0.65 per page copied and for first class postage as generally allowable under Connecticut state law.
I understand that I am under no obligation to sign this form and that Robert R. Palozej OD, LLC. may not condition treatment, payment, or enrollment/eligibility for benefits on my decision to sign this form. I understand that I may revoke this Authorization by notifying Robert R. Palozej OD, LLC. in writing of my revocation. I am aware that my revocation will not be effective as to uses and/or disclosures of the health information that the person(s) and or organization(s) listed above have already made in reliance on this Authorization.
This Authorization is valid for one year from today’s date or until