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HIPAA Authorization
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I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the practice's Privacy Officer at 1522 Claremont Ave., Ashland, Ohio 44805. I understand that a revocation is not effective to the extent that my provider has relied on the use of disclosure of PHI or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
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I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. This authorization expires three years from signed date.
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