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AUTHORIZATION TO USE, DISCLOSE, & RELEASE PROTECTED …

Form CC1162 AUTHORIZATION TO USE, disclose & RELEASE PROTECTED health information I understand the following: I have the right to refuse to sign this form for AUTHORIZATION to disclose or RELEASE my PROTECTED healthinformation. Refusal to sign the AUTHORIZATION will not a dversely affect my ability to receive health care servicesor reimbursement for services. The only circumstance when refusal to sign this AUTHORIZATION may affect myability to receive health care services is if the health care services are research-related or solely for thepurpose of providing health information to someone else and the AUTHORIZATION is needed to make thatdisclosure. There may be a fee associated with this request.

AUTHORIZATION TO USE, DISCLOSE, & RELEASE PROTECTED HEALTH INFORMATION I understand the following: • I have the right to refuse to sign this form for authorization to disclose or release my protected health

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