Authorization to Disclose/Obtain Health Information

00001341S Side 1 of 2 01/2024 ___E-mail: by selecting this option, although sent using encryption data software, the patient/recipient is aware this method may not be secure on the receiving end, however they are accepting the risk. Office use only Authorization to Disclose/Obtain Health Information This authorization permits Stormont Vail Health and/or Cotton O’Neil Clinics to disclose/ob [...] *I also understand that I may revoke this authorization at any time by delivering a written revocation to the Health Information Management Department (address on second page). [...] *I understand that Stormont Vail Health or Cotton O’Neil will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization. [...] *I authorize Stormont Vail Health/Cotton O’Neil to obtain/disclose the records/information described. [...] I am the patient listed or am authorized to act on behalf of the patient as the patient’s personal representative. [...] I also permit Stormont Vail Health/Cotton O’Neil to obtain/disclose the records/information upon presentation of a photocopy of this authorization. [...] The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation. [...] Violation of the Federal law and regulations of a treatment facility is a crime. [...] Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the treatment facility or against any person who works for the treatment facility or about any threat to commit such a crime. [...] Federal regulation prohibits you from making any further disclosure of this information except with the specific written consent of the person to whom it pertains. A general authorization for release of medical or other information if held by another party is not sufficient for this purpose. Federal regulations state that any person who violates any provision of this law shall be fined not more