1. I understand this authorization is voluntary and will not affect my eligibility for benefits, treatment, enrollment, or payment of claims.
2. I understand if the person(s)/organization(s) authorized to receive my protected health information is not a health plan or health care provider, privacy regulations may no longer protect the information.
3. I understand I may inspect or obtain a copy of the protected health information shared under this authorization by sending a written request to the address listed at the bottom of this form.
4. I acknowledge information authorized for release may include records, which may indicate the presence of a communicable or non-communicable disease.