I understand that my records are confidential and cannot be disclosed without my authorization, except when otherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected. I understand that the specific information to be released may include, but is not limited to history, diagnosis, and /or treatment of drug or alcohol abuse, mental illness, or communicable disease, including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS)

I understand that treatment or payment cannot be conditioned on my signing this authorization, except in certain circumstances such as participation in research programs, or authorization of release for testing for pre-employment purposes. I understand I may revoke this authorization in writing at any time by submitting it to the Privacy Officer for AccelHealth: the patient’s name, address, and patient number if applicable; the effective date of this authorization, and the recipients of the authorization, the date of revocation, and the patient’s signature.