Medical Records Authorization

 

  • Authorization: I authorize Colorado Clinic to obtain my protected health information from:

  • Rights This authorization is voluntary. I understand I do not have to sign this authorization in order to get health care benefits.

    I may revoke this authorization in writing at any time. If I do, it will not affect any actions already taken based upon this authorization.

    I am entitled to a copy of this authorization.

    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.