HIPAA Authorization Form

month/day/year

Revocation

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification.


Expiration

I understand that Karen Godfrey Choate, LLC will not condition my treatment on whether I give authorization for the requested disclosure.


Form of Disclosure

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.


Use mouse, trackpad to sign. Use finger on iPad, or iPhone.