I hereby authorize that the protected health information regarding the above-named person be forwarded to Grand Vein
Specialists, Ever Clinic
I understand that:
➔ The information in my health record may include information relating to ecually transmitted deseases,
acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include
information about behavioral or mental health services, and treatment for alcohol and or drug abuse.
➔ I have a right to revoke this authorization at any time. If I revoke this authorization, I must do so in writing.
This authorization shall remain valid unless revoked but will expire 1 year after signing.
➔ Revocation will not apply to information that has already been released in response to this authorization
➔ Once the above authorization is disclosed, there is a possibility that it may be re-disclosed by the recipient,
and therefore may not be protected by the federal privacy law regulations.
➔ Failure to provide all required information will not constitute a proper authorization to disclose protected
health information and that; therefore, my request may not be honored.
➔ Authorization to use or disclosure of the information identified above is voluntary. I need not sign this form
to ensure healthcare treatment. Pay or eligibility for benefits