(if left blank, 2 years of medical history and all pathologies are provided)
I understand that I have the right to revoke this authorization at any time, in writing, by mailing such written notification to the Practice’s Privacy Officer, at Helendale Dermatology & Medical Spa, 500 Helendale Road, Suite 100, Rochester, New York 14609
I understand that a revocation is not effective to the extent that the Helendale Dermatology has taken action in reliance on this authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the law provides the insurer with the right to contest a claim under the policy or to contest the policy itself.
I understand that Helendale Dermatology will not condition my treatment on whether I provide authorization for the requested use or disclosure if to do so would be prohibited by federal or state law. If a reason exists under law for conditioning my treatment on obtaining this authorization, I have been advised of that fact and of the consequences of me refusing to sign this authorization. I understand there is the potential for information used or disclosed pursuant to this authorization to be subject to re-disclosure by the recipient if the recipient is not required by law to protect the privacy of the information. I understand that I will receive a copy of this authorization if signed by me.
I hereby authorize the use or disclosure of my health information as described in this form.