I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment or enrollment). However, I do have to sign an authorization form:
- To take part in a research study, or
- To receive health care when the purpose is to create health care information for a third party
I may revoke this authorization in writing. If I did, it would not affect any actions already taken by PNW based upon this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. Two ways to revoke this authorization are:
- Fill out a revocation form. A form is available from PNW, OR
- Write a letter to PNW.
Once health care information is disclosed, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.