Consent Form/Authorization For Release of Information    Step 7 of 9

Please indicate how information should be exchanged with Karen Horney Clinic. Also include the name and address of the other person or organization receiving or sending the information.

INFORMATION TO BE RELEASED (If the box is checked, you are authorizing the release of that type of information). Please note: that unless all boxes are checked we may be unable to process your request.

I, or my authorized representative, authorize the use or disclosure of my medical and/or billing information as I have described on this form.

I understand that my medical and/or billing information could be re-disclosed and no longer protected by federal health information privacy regulations if the recipient(s} described on this form are not required by law to protect the privacy of the information.

I understand that if my medical and/or billing records contain information relating to ALCOHOL or SUBSTANCE ABUSE, GENETIC TESTING, MENTAL HEALTH, and/or CONFIDENTIAL HIV/AIDS RELATED INFORMATION, this information will not be released to the person(s} I have indicated unless I check the boxes for this information on this form.

I understand that if I am authorizing the use or disclosure of HIV/AIDS-related information, the recipient(s} is prohibited from using or re-disclosing any HIV/AIDS-related information without my authorization, unless permitted to do so under federal or state law. I also understand that I have a right to request a list of people who may receive or use my HIV/AIDS-related information without authorization. If I experience discrimination because of the use or disclosure of HIV/AIDS-related information, I may contact the New York State Division of Human Rights at 212.480.2493 or the New York City Commission of Human Rights at 212.306.7450. These agencies are responsible for protecting my rights.

I understand that I have a right to refuse to sign this authorization and that my health care, the payment for my health care, and my health care benefits will not be affected if I do not sign this form. I also understand that if I refuse to sign this authorization, Karen Horney Clinic cannot honor my request to disclose my medical and/or billing information.

I understand that I have a right to request to inspect and/or receive a copy of the information described on this authorization form by completing a Written request to access my records. I also understand that I have a right to receive a copy of this form after I have signed it.

I understand that I have the right to revoke (take back) this authorization it at any time, except to the extent that Karen Horney Clinic has already taken action based on my authorization or that the authorization was obtained prior to my revoking it. To revoke this authorization, please contact the facility Health Management department processing this request.

I have read this form and all of my questions have been answered. By signing below, I acknowledge that I have read and accept all of the above.