☐ - To authorize the using or disclosing party to sell my health information. I understand that the
seller will receive compensation for my health information and will stop any future sales if I
revoke this authorization.
This authorization ends: (check one)
☐ - On (date)__________________
☐ - When the following event occurs: _____________________________________________
II. My Rights
I understand that I have the right to revoke this authorization, in writing, at any time, except
where uses or disclosures have already been made based upon my original permission. I may
not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke
this authorization, I must do so in writing and send it to the appropriate disclosing party.
I understand that uses and disclosures already made based upon my original permission cannot
be taken back.
I understand that it is possible that information used or disclosed with my permission may be re-
disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.
I understand that treatment by any party may not be conditioned upon my signing of this
authorization (unless treatment is sought only to create health information for a third party or to
take part in a research study) and that I may have the right to refuse to sign this authorization.
I will receive a copy of this authorization after I have signed it. A copy of this authorization is as
valid as the original.
Signature of Patient: _________________________________
If the patient is a minor or unable to sign, please complete the following:
☐ - Patient is a minor: _____________ years of age
☐ - Patient is unable to sign because: ____________________________________________
Signature of Authorized Representative: _______________________________________