MON: 8:00AM-5:00PM TUES: 7:00AM-4:00PM WED: 7:00AM-4:00PM THURS: 9:00AM-6:00PM FRI: 7:00AM-4:00PM and 1X/MONTH 7:00AM -12:00PM SAT: 1X/MONTH 7:00AM to 11:30AM
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This authorization will expire 1 year from 09/29/2023.
I understand I may withdraw my authorization at any time by submitting a written request to the HIPAA Privacy Officer. I understand any revocation is not effective to the extent action has already been taken in reliance on this authorization. I understand information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by federal or state law. This authorization is not intended to affect a patient's ability to receive medical care.
Alcohol and Drug Abuse Treatment. To the extent my medical record contains information regarding alcohol or drug treatment that is protected by federal law, I authorize the disclosure of such information or record.
HIV / AIDS Information To the extent my medical record contains information regarding my HIV/AIDS status, treatment or testing, I authorize the disclosure of such information or record.
Behavioral Health Notes / Record I authorize the disclosure of any behavioral health notes or information in my medical record.
With my digital signature below, I consent to the release of the above listed information / documents.
Community Partner site to email this completed form to communitypartners@midwestern.edu. Midwestern will contact the patient to schedule an appointment within 48 business hours of receipt.
