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Wicomico County Health Department
RrblicHealthP_1r:lji..,y,._::yl::lqlbohico CourtyHeelth DcpertaeDt
If the information which the program has includes records or information from another entity,I XI ao o" ! do not wish to have that information released under this authorization.
108 East Main street o Salisbury, Maryland 21g01Lori Brewster, MS, APRN/BC, LCADC o Health Officer
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Expiration:Xox
This authorization will expire (comptete one):
ONE YEAR FROM DATE OF SIGNATURE
E ON OCCURRENCE OF THE FOLLOWING EVENT (WHICH MUST RELATE To THE INDIVIDUAL oRPURPOSE OF THE USE AND/OR DISCLOSURE BEING AUTHORIZED):
Right to Revoke: I understand that I may revoke this authorization at any time by giving written norice of my revocation to WiCHD. Intlrder to obtain a revocation form to revoke this authorization, I understund thut t m-ay colntact the oftice ol the wiCHD HealthOfficer/Deputy Health Officer. I understand that revocation of this authorization will not afl'ect any action that WiCHD or others namedor unnamed took in reliance on this authorization before WiCHD received my written notice of revocation.SECTIoN D: sienature: To the Individuar - please read the firllowing.I AUTHORIZE THE USE AND/OR DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN SECTION B ABOVE. IUNDERSTAND THIS AUTHORIZATION IS VOLUNTARY.I unclcrstand that ifthe persons or organizations I authorize to rcccive and/or use my health information arc not subjcct to the federat orstate health information privacy laws, they might turthcr disclose thc hcalth information, and it may no longer be piotected by the healthintbrnration privacy laws.If the retluest for information conccrns treatment ol'alcohol or other substance abuse, the confidentiality of the information is protected byfederal law 42 CFR Part 2.I have had full opportunity to read and consider the contenls of this authorization, and I conflrm that the contents are consistent with myintent.
Signature:
Date:
Il personal representative is making this request, a copy of any document granting legal authority is required. Complete the fbllowing:Personal Representative's Name:
Relationship to Individual:
4lO-749-1244 . F'AX 410-543-6975 o TI)D 4tO-S43-6952 o WTCoMIOoHIIALTFI.ORGMARYLAND DEPARTMENT oF rtEAllrrt o HDALTH.MARYLAND.(\oy c 877-463-3464AF'FIRMA'I'IVE ASTION AND EQUAL OPPOR'I'T'NITY trMPLOYER AND PROVIT)ER
TO THE
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