(a) I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I do not need to sign this form to assure treatment. However, if this authorization is needed for participation in a research study, my enrollment in the research study may be denied.
(b) I understand that I may inspect or obtain a copy of the information to be used or disclosed.
(c) I understand that I have the right to obtain an electronic copy if readily reproducible in that format.
Please Note: Our office may charge a fee for medical record copying. The fee is $30.00 for the first 15 pages and $0.25 for each page thereafter. If you request that your records, be sent to another health care provider for continuing care, as a courtesy, the records will be copied at no charge and sent directly to the specified health care provider.