I hereby authorize and request Regional Primary Care, Inc. to use and disclose my personal, private Protected Health Information including release of a copy of my medical record or a specified portion of my medical record as indicated below on this form. I understand that the information I am authorizing Regional Primary Care, Inc. to release to the person, class of persons or organization named below may be re-disclosed and no longer protected by federal privacy regulations.
I understand that I may revoke this authorization at any time by in writing and that I may use a form furnished by Regional Primary Care, Inc. to make the written revocation. I also understand that if I revoke this authorization, my revocation will not affect any health information that was released according to the terms of this authorization before the date of my revocation. I also understand that I may not revoke authorized use and/or disclosures obtained in connection with my receipt of insurance coverage.
I understand that this authorization is voluntary, my treatment by Regional Primary Care, Inc. will not be conditioned on the completion of this authorization and I have a right to request and receive a copy of this authorization.