Release of Authorization

Authorization for Use and Release of Protected Health Information

  • I understand that my treatment, payment, enrollment, or eligibility for services will not be conditioned on whether I sign this form. I understand that I have the right to refuse to sign this authorization. I understand that personal health information used or disclosed pursuant to this authorization may be redisclosed by the recipient and its confidentiality may no longer be protected by federal or state law.
  • This authorization is effective for a period of one (1) year from the signature date or as otherwise specified.

    After the effective date, this Authorization to use or disclose this Protected Health Information expires. I understand that I have the right to revoke this Authorization, in writing, at any time by sending such written notification to Chosen, located at 351 Main Plaza, New Braunfels, Texas 78130. This authorization has been read to me/or by meand I understand its meaning.