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Mountain Valley Medical Clinic
38 Route 11 P.O. Box 310
Londonderry, Vermont 05148-0310
Telephone No: (802)824-6901 • Fax No: (802) 824-3602
Protected Health Information
Release Authorization
Full Name:
_______________________________________________ Date of Birth: ____________________
This will
authorize ________________________________________________________ to use or
disclose my
protected
health information to MVMC as described below for the following purpose:
________________________________________________________________________________________
________________________________________________________________________________________
__ Complete
copy of medical record
__ Psychotherapy Notes Only (If applicable, no other
information may be included in authorization)
__ Other
(describe): ________________________________________________________________________
Dates of
care included: ___________________________________ to ________________________________
The
information authorized for disclosure may relate to (check all that apply):
__ Mental
illness (excluding psychotherapy notes) __ HIV-related
illness __ AIDS
__ Drug or alcohol treatment (further redisclosure prohibited or governed by 42
CFR Part 2.)
__ I understand
that I may inspect or copy the protected health information described by this
authorization.
__ I
understand that this authorization may be revoked in writing and delivered to
MVMC at any time, although revocation will not be effective as to the disclosure
of records whose release I have previously authorized, or where other action
has been taken in reliance on an authorization I have signed.
__ I
understand that information used or disclosed pursuant to this authorization
could be subject to redisclosure by the recipient and, if so, may not be
subject to federal or state law protecting its confidentiality.
__ [I
understand that the (covered entity) shall not condition treatment, payment or
enrollment in the health plan or eligibility for benefits on my providing
authorization for the requested use or disclosure AND THAT I MAY REFUSE TO SIGN
THIS AUTHORIZATION.]
__ [I
understand that (covered entity) shall have the opportunity to obtain direct or
indirect remuneration in the nature of (describe): _______________________from
[third party] as a result of this authorization.]
_____________ __________________________________________________________
Date Signature of
individual or representative
__________________________________________________________
(Authority
or relationship of representative)
***************
EXPIRATION DATE: This authorization will expire on
[date or event ______________________
(If no date or event is stated,
expiration is six months from the date it was signed.)
COPY PROVIDED: MVMC shall provide a copy
of this authorization, when signed, to the subject individual if
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