Purpose and scope: At my request, the provider named above may disclose the records I selected to Dr. Krueger, Dr. Taylor, and Dr. Baca — MMjCCC Gentle Wing LLC for continuity of care and treatment. This authorization excludes specially protected records unless I separately select or authorize them below. It does not include psychotherapy notes or substance-use-disorder counseling notes; those notes require a separate authorization or consent.
1. Expiration: This authorization expires 18 months after the patient signs this release.
2. Right to revoke: I may revoke this authorization in writing by delivering a signed and dated revocation to the records provider named above, including by fax to the provider fax number entered above. Revocation is effective when received, except to the extent a person or entity has already acted in reliance on this authorization.
3. Re-disclosure: Information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule.
4. Voluntary authorization: I may refuse to sign this authorization. My refusal will not affect treatment, payment, enrollment, or eligibility for benefits. I provide this authorization voluntarily.
5. Copies: A photocopy, electronic copy, or fax of this signed authorization may be treated as an original. I am entitled to a copy of the signed authorization.
6. Substance-use records: Substance-use-disorder records remain protected from use or disclosure in civil, criminal, administrative, or legislative proceedings against me unless I separately consent in writing or a court order permits that use or disclosure after notice and an opportunity to be heard.
State-specific term: Arizona-specific notice. Communicable-disease information, including HIV-related information, is excluded unless the signer specifically authorizes that disclosure below for continuity of care and treatment.