I request and authorize Mosaic Diagnostics to disclose the protected health information indicated below to the recipient indicated below.
This protected health information is disclosed at my request in compliance with 45 CFR 164.508(c)(1)(iv).
I acknowledge that I have the right to revoke this authorization, in writing, by sending written notification to Mosaic Diagnostics. However, I understand that any actions already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
I acknowledge the potential for information disclosed pursuant to this authorization to be subject to redisclosure by the recipient and no longer be protected under HIPAA privacy rules.
I understand that Mosaic Diagnostics may not condition treatment, payment, enrollment or eligibility for benefits on whether or not I sign the authorization.
Any facsimile, copy or photocopy of the authorization shall authorize Mosaic Diagnostics to release the records herein.