By completing, signing, and submitting this form you authorize to release contained in your medical record (including, if applicable, information about HIV Infection or AIDS, information about substance abuse treatment and information about mental health services).
The information will be release to:
Essential Telehealth 280 Collingwood Drive Ann Arbor, MI 48103 Phone: 734.369.0607 Fax: 734.939.1110
For mental health records, or records pertaining to HIV infoection or AIDS, the Purpose of Need For Such Disclosure section must include a statement as to how the information is relevant to the purpose and need for such disclosure
By providing your digitial signature below, you understand that you have a right to revoke this authorization at any time. You understand that if you revoke this authorization, you must do so in writing and present the written recovation to the Essential Telehealth Medical Records Department. We may have already releasedd the information based on your original authorization. We will not release any additional information after we recieve you revocation. We will not condition treatment or payment based on this authorization or revocation of authorization unless ortherwise allowed by law.
Your protected health information will be disclosed in this authorization. This authorization will expire one (1) year from the date of submission, or until we have completed the disclosure you've requested, whichever is shorter. This information could be sibject to re-disclosure by the recipient and may then no longer be protected.