I understand that by completing and submitting this form, I may be providing protected health information (PHI). I authorize the receiving provider, laboratory, or organization to use and disclose my PHI for the purposes of evaluation, treatment, payment, and healthcare operations, including contacting me regarding services, results, or follow-up care. I acknowledge that this authorization is voluntary, that I may revoke it at any time in writing, and that any revocation will not apply to information already used or disclosed. I also acknowledge that I have been offered access to the organization’s Privacy Policy, which includes the HIPAA Notice of Privacy Practices.
