Completion of this document authorizes the use and disclosure of health information about you.
By clicking or opting in, I hereby authorize the disclosure to and from Cerebral Medical Group of all health information pertaining to my medical history, mental and/or physical condition, and treatment received, including demographic information, financial information (including but not limited to payment card information), and health plan benefits billing information for purposes of my care. This disclosure will include my mental health information, to the extent applicable.
Pursuant to this Authorization, my health information may be disclosed so that Cerebral Medical Group may provide treatment and services to me. Disclosure (for example, to a pharmacy) may also be made for the purposes of prescription fulfillment, related billing, and all activities related to such purposes. Disclosure may also be made for the purposes of Cerebral Medical Group obtaining reimbursement for the services provided to me, including billing, insurance claims submission, and all activities related to such purposes.
This Authorization is valid for five (5) years from the date hereof, or for the duration permitted under applicable state law, whichever is earlier.
I understand that, except to the extent that a lawful holder of my information has acted in reliance on this Authorization, I have the right to revoke this Authorization, in writing, at any time by sending such written notification to the entity disclosing my information.
I understand that information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient of such information and may no longer be protected by Federal or State law. Neither the entity disclosing my information nor Cerebral Medical Group will condition my treatment on whether I provide authorization for the requested use or disclosure except as otherwise permitted by law.
I understand that I have the right to: inspect or copy the information to be used or disclosed as permitted under Federal or State law; refuse to authorize this Authorization; and receive a copy of this Authorization. I have read the above information and authorize the disclosure of my information for the purpose described herein.
By clicking or opting in, I acknowledge that I have read and agree to the terms of this Authorization.
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