YOUR RIGHTS:
• You may refuse to sign this authorization.
• Refusal will not affect your ability to obtain treatment or your eligibility for benefits through your care provider.
• You may revoke this authorization at any time. Revocation will take effect immediately.
• You have a right to receive a copy of this authorization.
REMUNERATION:
By clicking “submit,” you acknowledge that your care provider will not disclose nor directly receive any money for the use of your health information provided for this program.
|
