By initialing the space below, I specifically authorize the release of the following medical records, if such records exist:
Your health care and payment for that health care cannot be conditioned upon receipt of this signed Authorization unless your health care or treatment is for the purpose of: Creating health information about you to be disclosed to a third party; or for the purpose of research Patient Rights: I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment, or enrollment). I may revoke this authorization in writing. If I do, it will not affect any actions already taken by West Bend Family Medicine based upon this authorization. I may not be able to revoke this authorization if its purpose were to obtain life insurance. To revoke this authorization, I must write a letter to West Bend Family Medicine. This information may be subject to re-disclosure and may no longer be protected by federal or state privacy laws. This Authorization expires 180 days from the date of this signed Authorization.
I have read this authorization and understand it: