I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity,
and I consent to such disclosure for these permitted uses, including disclosures via fax.
Further, I permit a copy of this authoriztion to be used in place of the original, and request payment of medical insurance benefits either to myself or the party who accepts assignment.
Regulations pertaining to medical assignment of benefits apply.
I fully understand and accept the terms of this consent.