I understand that if the person(s) and/or organization(s) listed above are not health care providers, health plans, or health care clearinghouses, who must follow the federal privacy standards, the health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards and my health information may be redisclosed without obtaining my authorization.
Right to receive a copy of this authorization - I understand that if I agree to sign this authorization, which I am not required to do, I must be provided with a signed copy of the form.
Right to refuse to sign this authorization - I understand that I am under no obligation to sign this form and that the person(s) and/or organization(s) listed above who I am authorizing to use and/or disclose my information may not condition treatment or payment, on my decision to sign this authorization.
Right to withdraw this authorization - I understand written notification is necessary to cancel this authorization. To obtain information on how to withdraw my authorization or receive a copy of my withdrawal, I may contact the privacy director at 702-690-9711 or support@cirrusmed.com. I am aware that the revocation will not apply to the information that has already been released in response to this authorization.