Authorization for Release of Medical Records

I authorize the clinic or provider listed above to release my protected health information to the clinic(s) or provider(s) indicated as the authorized recipient(s).

This authorization will automatically expire in 90 days from the date of your signature, or fulfillment of the record release request. This Authorization may be revoked at any time by the patient or authorized representative in writing.

I understand that this information may include any history of acquired immunodeficiency syndrome (HIV or AIDS), sexually transmitted diseases, psychiatric care, and treatment for substance abuse, or similar sensitive information. I am aware that I may refuse to sign this authorization. I further understand that I have the right to inspect any protected health information to be disclosed.

I understand that Biosymmetry assumes no responsibility for the use or misuse by others of my protected health information. I have had the opportunity to discuss any concerns about the privacy of my protected health information and to discuss Biosymmetry's privacy policy. Federal law states that treatment, enrollment or eligibility for benefits may not be conditioned upon obtaining this authorization, if such conditioning is prohibited by the Privacy Rule.

Federal law also requires a statement that there is the potential that the protected health information released under this authorization may be subject to re-disclosure by the recipient.