This authorization is to release information to:
Fourth Street Clinic 

The purpose of this disclosure is:
For medical conditions review and health history for placement into the MVP. 

Specify Dates of Service

(if no date are specified, please allow access to all record dates)

(unless otherwise noted above this authorization will remain in effect 180 days from the date signed.) 

I understand that: Once this facility discloses my health information by my request, it cannot guarantee that Recipient will not re-disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information. I may make a request in writing at any time to the Medical Records Department to inspect and/or obtain a copy of my health information maintained at this facility as provided in the Federal Privacy Rule 45 CFR § 524. The Fourth Street Clinic has 30 days to provide a copy of my records. My records are protected and cannot be disclosed without my permission. *Alcohol/drug treatment records are protected by federal rule 42 CFR, part 2. This authorization will remain in effect until the Authorization expires or I provide a written notice of revocation to the Fourth Street Privacy Office.

To be used if facility requests this authorization: I understand that: I may refuse to sign or revoke this Authorization at any time for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of this facility's treatment of me, enrollment in the health plan, or eligibility for benefits. I understand that a revocation will not apply to information that has already been released in response to this authorization. I may make a request in writing at any time to the Medical Records Department to inspect and/or obtain a copy of protected health information maintained at this facility to be used or disclosed as provided in the Federal Privacy rule 45 CFR § 164.524. If l have questions about disclosure of my health information, I can contact the Privacy Officer/Medical Records Department.

BY SIGNING, YOU INDICATE THAT YOU HAVE READ, UNDERSTAND, AND AGREE TO THESE TERMIS, AND THAT YOU ARE THE PATIENT, THE GUARANTOR, THE PATIENT’S LEGAL REPRESENTATIVE, OR YOU ARE LEGALLY AUTHORIZED TO SIGN THIS AGREEMENT AND ACCEPT THESE TERMS.