I hereby authorize the use/disclosure of my health information as described below. I understand that this authorization is voluntary. I understand that any and all records, whether written, oral, or electronic format are confidential and cannot be disclosed without my prior written authorization except as otherwise provided by law. I understand that a photocopy or fax of this authorization is as valid as the original. Rushmore OB/Gyn cannot condition treatment, payment, enrollment, or eligibility for benefits on this authorization.
I understand that I may revoke this authorization in writing; except to the extent that records or information have already been provided to/from Rushmore OB/Gyn. I understand that once Rushmore OB/Gyn receives records (if applicable), they will be protected by the Privacy Rule. I understand that if I am authorizing Rushmore OB/Gyn to release information to another entity that is not bound by the Privacy Rule, the information is no longer protected by the Privacy Rule and that entity may re-disclose the information. This authorization will expire once the information has been released or received or 1 year after the date of the said authorization.