hereby authorize TOPS Comprehensive Breast Center to use or disclose the following protected health information:
The protected health information may be disclosed to: (Please provide the name of the person(s) or entities to whom the protected health may be disclosed. If the records are to be mailed please provide the name and address where to be mailed.)
The protected health information is being used or disclosed for the following purposes: (If the disclosure is at the patient’s request and the not choose to provide an explanation, the patient may indicate “At the patient’s request.” Otherwise, please provide the specific purpose(disclosure.)
This authorization will become invalid 180 days from the date of signature unless revoked earlier. A copy or facsimile of this authorization is the original.
I understand that, as set forth in the Provider’s Privacy Notice, I have the right to revoke this authorization at any time by sending written notice to:
TOPS Surgical Specialty Hospital
17080 Red Oak Dr.
Houston, TX 77090
Attn: Privacy Officer
I understand that a revocation is not effective to the extent that the Provider has taken action or relied on the authorization that is being revoked.
I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may not be protected by federal or state law.