Authorization for Use of Disclosure of Protected Health Information

Information to be Released

Purpose of Disclosure

Acknowledgement of Understanding

• I understand the expiration date of this authorization is 1 year.
• I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the date notified except to the extent action has already been taken.
• I understand that Center for Reproductive Medicine cannot prevent the redisclosure of records released as a result from this request; therefore Center for Reproductive Medicine is released from any and all liability resulting from redisclosure.
• I understand by authorizing this use or disclosure of information, there will be no conditions placed on my health care or payment for my health care.

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