I hereby authorize Relentless Hope to inquire and receive information regarding my medical records as it relates to scope exams to identify internal scarring of the uterus, vagina and colon. This information is for my personal and professional wellbeing and success. Relentless Hope may provide a redacted copy of the exam reports to the donor who pay for these serves. HIPAA rules apply to this request and I understand that confidentiality will be strictly adhered.
I understand this information is being requested for the purpose of: Coordination of service delivery, treatment or legal purposes.
I understand I have a right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to the Executive Director of Relentless Hope. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition. If I fail to specify an expiration date, event or condition, this authorization will expire 90 days from the date of termination of my file.
I understand that authorizing the disclosure of this health and other information is voluntary. I can refuse to sign this authorization. I understand that I may inspect or obtain a copy of the information to be used or disclosed. I understand that my medical reports will be redacted to protect my identity. If I have any questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure.
