I will not receive remuneration for releasing my PHI for the purpose(s) listed above. I hereby release UNC Health and its affiliates and employees from any and all liability that may arise from the release of my PHI as authorized by this form. I have the right to revoke this Authorization at any time if I do so in writing and address it to the person or institution named above. The revocation will not apply to any information already released as a result of this Authorization. I may refuse to sign this Authorization, and I cannot be denied or refused treatment if I refuse to sign and my refusal to sign this Authorization will not affect my treatment, payment, enrollment or eligibility for benefits or the quality of care I receive. Once information is disclosed pursuant to this Authorization, it is possible that it will no longer be protected by the federal medical privacy laws and could be re-disclosed by the person or agency that receives it. This Authorization shall not have an expiration date and shall remain in effect unless and until I provide my written revocation made to the UNC Health office, facility or health care provider listed above. My signature below indicates that I am giving permission for the use and disclosure of the PHI described above
My signature below indicates that I am giving permission for the use and disclosure of the PHI described above.