I authorize the Office of Dr. Christopher N. Siachos, to use of disclose my health information to the following persons:
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 will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.