I acknowledge I have read and agree with the HIPAA policy. If for any reason I am unable to pick up my personal records, I understand Global Imaging office policy requires proof of family/friend identity to release my information.
This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal
Regulation (42 CFR Part 2) prohibits you from making any further disclosure of this information without specific written
consent of the person to whom it pertains, or otherwise as permitted by such regulations.
A GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMATION IS NOT SUFFICIENT FOR THIS PURPOSE.