Purpose: I understand that the purpose of this authorization is to allow my healthcare provider to disclose my health information to appropriate agencies or organizations involved in breast and cervical cancer screening programs.
Information Disclosure: I authorize my healthcare provider to disclose relevant health information, including but not limited to medical history, laboratory test results, imaging studies, and treatment records, to authorized personnel involved in the screening program.
Confidentiality: I understand that my health information will be treated confidentially and will only be disclosed to authorized individuals or entities involved in the breast and cervical cancer screening program. I acknowledge that appropriate safeguards will be in place to protect the privacy and security of my health information.
Purpose Limitation: I understand that my health information will only be used for the purpose of determining my eligibility for breast and cervical cancer screening and will not be disclosed for any other purpose without my further authorization, except as required by law.
Right to Revoke: I understand that I have the right to revoke this authorization at any time by providing written notice to my healthcare provider. However, I acknowledge that revoking this authorization may affect my eligibility for breast and cervical cancer screening services.
Signature: By signing below, I acknowledge that I have read and understood the terms of this informed consent and authorization to disclose health care information. I voluntarily consent to the disclosure of my health information for the purpose described above.