APN Connection HIPAA Patient Authorization
If you would like to access and use the Community, please review and agree to the terms of this Patient Authorization.
IF YOU AGREE TO THE TERMS OF THIS PATIENT AUTHORIZATION, YOUR INFORMATION WILL NO LONGER BE PROTECTED BY HIPAA and 42 CFR Part 2.
I understand that consenting to this Authorization is voluntary and that I may refuse to sign this authorization by checking “I Do Not Agree to the terms of the Patient Authorization.” APN Lodge may not condition treatment, enrollment or eligibility for benefits on my signing this Authorization.
I understand that I may revoke this authorization at any time by emailing email@example.com with my name and a request to revoke my Patient Authorization. My revocation will be effective upon its receipt by APN Lodge. My revocation will not be effective to the extent that APN Lodge has acted in reliance on this Authorization. If I do not revoke this Authorization, it will expire after (2) years from the date I agree to this Authorization, whichever is sooner. I understand that if my information is disclosed, it may be subject to redisclosure by the recipients and no longer protected by HIPAA. I also understand that I am entitled to a copy of this Patient Authorization.
By checking “I Agree to the terms of the Patient Authorization” and clicking on “Submit,” I understand that I will be signing this Authorization.
- I Agree to the terms of the Patient Authorization.
APN Lodge’s Notice of Privacy Practices may be viewed at [link].