I authorize Primary Care Physicians of Hollywood
to use and disclose a copy of the specific health and medical
information described below regarding:
If we are requesting this Authorization from you for our own use and disclosure or to allow another health
care provider or health plan to disclose information to us:
We cannot condition our provision of services or treatment to you on the recipient of this signed
- You may inspect a copy of the protected health information to be used or disclosed;
- You may refuse to sign this authorization; and
- We must provide you with a copy of the signed authorization.
You have the right to revoke this authorization at any time, provided that you do so in writing and except to
the extent that we have already used or disclosed the information in reliance on this authorization.
Unless revoked earlier or otherwise indicated, this authorization will expire 180 days for the date of signing or
shall remain in effect for the period reasonably needed to complete the request.
I have reviewed and I understand this authorization. I also understand that the information used or disclosed
pursuant to this authorization may be subject to re-disclosure by the recipient and no longer be protected
under federal law.