Patient Rights and Notices:
I understand that once my records are released, they may be re-disclosed by the recipient and may no longer be
protected by HIPAA.
I understand that I have the right to receive a copy of this authorization.
Treatment, payment, or eligibility for benefits will not be conditioned on signing this authorization.
This authorization will expire one (1) year from the date signed below unless otherwise specified.
I understand that I may revoke this authorization at any time by submitting a written request to Synergy Medical Group, Except to the extent that action has already been taken in reliance on it.
