I understand I do not have to sign this authorization in order to receive treatment. However, I may be required to sign this authorization form:
I may revoke this authorization at any time, in writing, sent to Corneal Consultants of Colorado, P.C., at the address provide below. If I do, it will not affect any actions already taken by Corneal Consultants of Colorado, P.C., based upon this authorization; uses and disclosures already made cannot be taken back. I may not be able to revoke this authorization if its pupose was to obtain insurance.
Once the office discloses health information, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.
I will receive a copy of this authorization after I have signed it. A copy of this authorizaiton is as vallid as the original.
This medical record may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment. Separate consent must be given before this informaiton can be released.
This medical record may contain information concerning HIV testing and/or AIDS diagnosis or treatment. Seperate consent must be given to have this information released.