[{"id":"788e1656-e80a-45de-8453-c9f5ea230614","order":1,"text":"AUTHORIZATION FOR THE USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION","fontSize":"20","textAlign":"center","bold":true,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"75cfa7fa-9f6b-4dc8-a140-21f95eb4cf96","order":2,"text":"(HIPAA Medical Records Release Authorization)","fontSize":"14","textAlign":"center","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"88ae1d32-5353-436a-9f93-2ed977d44c09","order":3,"text":"This Authorization is executed pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations at 45 CFR Parts 160 and 164, including 45 CFR § 164.508. By signing this document, the individual identified below (the "Patient") authorizes the use or disclosure of his or her protected health information ("PHI") in the manner, to the person or entity, and for the purposes described herein. This Authorization is intended to satisfy the requirements of HIPAA and of any applicable, more protective law of the State identified below; where state law affords the Patient greater protection, that law controls.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"d053ea7d-df6d-4cc2-825d-a4fdee49975c","order":4,"text":"INDIVIDUAL WHOSE INFORMATION WILL BE DISCLOSED ("Patient")","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"5c178836-2970-4f37-86e7-f0d1f6110bcf","order":5,"text":"Full legal name: [Patient full name] Former or other names used (if any): [Former / other names]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"e58cb6e0-e173-49f2-83fa-50d80640fe87","order":6,"text":"Date of birth: [Date of birth] Social Security number (last 4 digits, optional): [____]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"abe4efd4-ade2-4886-b76e-e631a2f7a44f","order":7,"text":"Address: [Street address], [City], [State] [ZIP]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"77db9795-0204-4d6f-aa60-320a5d832677","order":8,"text":"Telephone: [Telephone] Medical record number (if known): [Medical record number]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"6afe11b9-07fc-474a-bb2c-e8d0120feae7","order":9,"text":"CAPACITY IN WHICH THIS AUTHORIZATION IS SIGNED","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"f8a7b8e3-6959-406a-b0d6-943bb096db58","order":10,"text":"This Authorization is signed by the Patient personally, who is an adult with legal capacity to authorize the disclosure of his or her own protected health information.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"b3ff5548-f9f0-459b-b0af-cc18a6d82c95","value":"self","type":"add","operator":"="}]},{"id":"8f3429dd-4475-42c0-b8f9-2b8bc42536d5","order":11,"text":"This Authorization concerns a Patient who is a minor. It is signed by the person identified below as the minor's parent or legal guardian, who represents that he or she has lawful authority to authorize the disclosure of the minor's protected health information. The Patient and the parent/guardian acknowledge that, under certain federal and state laws, a minor may control the disclosure of specific categories of information (such as reproductive health, mental health, or substance use disorder treatment), and that this Authorization does not override any such right the minor may hold.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"b3ff5548-f9f0-459b-b0af-cc18a6d82c95","value":"minor","type":"add","operator":"="}]},{"id":"d2d5ca24-df3f-4f8f-874a-6a742d8f57ca","order":12,"text":"This Authorization is signed by a personal representative acting on behalf of the Patient. The representative represents that he or she holds legal authority to act for the Patient (for example, as attorney-in-fact under a durable power of attorney, court-appointed guardian, or conservator) and shall, upon request, furnish written documentation of that authority.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"b3ff5548-f9f0-459b-b0af-cc18a6d82c95","value":"rep","type":"add","operator":"="}]},{"id":"9e58b8d3-6abf-4b15-b656-f87490327657","order":13,"text":"This Authorization concerns a deceased Patient and is signed by the personal representative, executor, or administrator of the Patient's estate, who represents that he or she is authorized to act with respect to the deceased Patient's protected health information. The Patient's protected health information remains protected under 45 CFR § 164.502(f) for the period required by law.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"b3ff5548-f9f0-459b-b0af-cc18a6d82c95","value":"deceased","type":"add","operator":"="}]},{"id":"f52dfb94-2812-46ec-9ec4-3b7d3959b5f1","order":14,"text":"Name of signer (representative): [Representative name]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"b3ff5548-f9f0-459b-b0af-cc18a6d82c95","value":"self","type":"remove","operator":"="}]},{"id":"5bb81764-5d91-4793-84ff-112328061149","order":15,"text":"Relationship to Patient / basis of authority: [e.g., parent, legal guardian, attorney-in-fact, executor]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"b3ff5548-f9f0-459b-b0af-cc18a6d82c95","value":"self","type":"remove","operator":"="}]},{"id":"5adeed8e-6914-43c1-8314-63224738a1ce","order":16,"text":"PERSON OR ENTITY AUTHORIZED TO MAKE THE DISCLOSURE","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"836fbb9d-94b7-44a1-820b-4ba159d4c0e1","order":17,"text":"The following health care provider, health plan, clearinghouse, or other covered entity (or business associate acting on its behalf) is authorized to use or disclose the Patient's protected health information as described in this Authorization:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"acf21ec1-7f4a-42ed-b1dd-fc57751e0520","order":18,"text":"Name: [Name of provider / facility / health plan]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"1628355b-8ecb-490c-a9a3-edbd6bdb8bc6","order":19,"text":"Department / custodian of records (if any): [e.g., Health Information Management]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"717f3550-e275-4df1-ba1a-b642772617cf","order":20,"text":"Address: [Address], [City], [State] [ZIP]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"dc6f6eb0-baad-47c7-a71d-5fc2e1851250","order":21,"text":"Telephone / fax: [Telephone / fax]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"f1d8268f-76c4-4453-8c7e-2190ad9d8bfb","order":22,"text":"PERSON OR ENTITY AUTHORIZED TO RECEIVE THE INFORMATION","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"ce56385a-47f2-40b7-8f08-ca7cb1bc1f94","order":23,"text":"The protected health information described below is authorized to be disclosed to the following recipient:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"567b3b66-1602-43f6-8978-9f3c81ee3d9f","order":24,"text":"Name: [Name of recipient]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"5f163386-5655-490f-9d6f-918af7a2388d","order":25,"text":"Relationship to Patient: [e.g., self, family member, attorney, insurer, physician]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"10fb6907-e29b-4932-b2e1-b82617706ffd","order":26,"text":"Address: [Address], [City], [State] [ZIP]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"f0da90ff-dd34-4749-b415-bf39580d3799","order":27,"text":"Telephone / fax / email: [Telephone / fax / email]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"d7747cc4-daee-4242-9fa6-eab15dcd145d","order":28,"text":"DESCRIPTION OF THE INFORMATION TO BE USED OR DISCLOSED","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"49a1f4c9-1ecf-4a3a-b81f-86a544812ba5","order":29,"text":"Scope of records. In a specific and meaningful manner as required by 45 CFR § 164.508(c)(1)(i), the Patient authorizes the disclosure of the following protected health information:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"5af0ba12-0f06-4c6e-9037-cb55810df012","order":30,"text":"The complete medical and billing record, including but not limited to records of diagnosis, treatment, examinations, history and physical reports, laboratory and diagnostic test results, consultations, progress notes, physician and nursing notes, operative and pathology reports, imaging and radiology reports and images, discharge summaries, immunization records, medication and prescription records, care plans, correspondence, and billing, claims, and payment records maintained by the disclosing party, in whatever form or medium maintained.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"4c27e304-c759-4f79-93be-01ee4fb83d6a","value":"complete","type":"add","operator":"="}]},{"id":"adf8be7b-83d6-42f7-b886-826bec92e0df","order":31,"text":"Only the following specific records, for the date(s) of service or period indicated: [Describe the specific records, dates of service, or treatment episodes].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"4c27e304-c759-4f79-93be-01ee4fb83d6a","value":"specific","type":"add","operator":"="}]},{"id":"8569c98d-7195-4d63-b88c-ee2221dd5c8b","order":32,"text":"Date range of the records to be disclosed: from [Start date] to [End date].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"8f3afaa4-5030-4d2d-b5dd-d82a2f14aede","value":"1","type":"add","operator":"="}]},{"id":"4a630a68-112f-4bad-9916-782f2231c56d","order":33,"text":"Format and manner of disclosure. The information shall be provided in the following format: [Paper copy]. Where an electronic copy is requested, it shall be provided in a readily producible electronic form and format, through a secure and reasonable means of transmission.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true},{"id":"dd6092e4-9972-4ddf-8f4f-b651b7b1ecc9","order":34,"text":"SPECIALLY PROTECTED INFORMATION — SPECIFIC AUTHORIZATION REQUIRED","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"46cdb4d3-c81b-49a4-bb7a-a2920a5f70de","order":35,"text":"Certain categories of information are subject to heightened legal protection under federal and state law and may not be disclosed without the Patient's specific, written authorization. The Patient specifically authorizes the disclosure of only the categories selected below. Where indicated, the Patient (or authorized signer) shall place his or her initials on the corresponding line to confirm the separate authorization; if no category is selected, the disclosing party shall redact such information from the records released.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"12","cflou":false,"active":true},{"id":"ea41c9a6-5e12-4e70-aef2-076bd185b686","order":36,"text":"HIV / AIDS. The Patient specifically authorizes the disclosure of information concerning HIV / AIDS testing, diagnosis, or treatment. Patient's initials: ______","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"fbd22ef2-b3e5-46e2-b755-808be30d2b26","value":"1","type":"add","operator":"="}]},{"id":"c4fb20f6-24fb-4ea3-a0ff-d2dbd70de20f","order":37,"text":"Substance use disorder (42 CFR Part 2). The Patient specifically authorizes the disclosure of records relating to the diagnosis or treatment of alcohol or drug abuse that are protected under 42 CFR Part 2. Patient's initials: ______","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"b8730f31-ff34-4cff-ae39-0e6f8e625479","value":"1","type":"add","operator":"="}]},{"id":"51c84224-5ff2-441f-861f-0f6d30a9e6b0","order":38,"text":"Psychotherapy notes (45 CFR § 164.508(b)(3)). The Patient understands that psychotherapy notes may not be authorized on the same form as any other protected health information and are released only by this separate, specific election. The Patient specifically authorizes the disclosure of psychotherapy notes. Patient's initials: ______","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"f6cfdcdf-5084-4f68-b06b-1b4c6e5b25d4","value":"1","type":"add","operator":"="}]},{"id":"58a4a37b-8a01-4684-b5b3-4163f6584b6d","order":39,"text":"Mental and behavioral health. The Patient specifically authorizes the disclosure of mental health and behavioral health treatment information (other than psychotherapy notes, addressed separately above).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"b4e74b87-2c89-47e7-8117-ee1f85377cec","value":"1","type":"add","operator":"="}]},{"id":"79d3c9b2-5069-49d1-b53b-816782ee05b3","order":40,"text":"Genetic information (GINA). The Patient specifically authorizes the disclosure of genetic testing information protected under the Genetic Information Nondiscrimination Act.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"b8775bb9-384a-4498-bb6e-e2a900e40834","value":"1","type":"add","operator":"="}]},{"id":"9d4a5c11-65ae-4db5-b972-438b0ccde950","order":41,"text":"Sexually transmitted diseases / reproductive health. The Patient specifically authorizes the disclosure of records relating to sexually transmitted diseases or reproductive health.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"0648b311-3b3f-4136-80b9-c0db2606dfa1","value":"1","type":"add","operator":"="}]},{"id":"4692e1e7-786e-498d-90d5-adb927542049","order":42,"text":"PURPOSE OF THE USE OR DISCLOSURE","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"bb37a47c-f2b5-41ef-9b87-dfedae50755e","order":43,"text":"The Patient authorizes the use or disclosure described above for the following purpose: [Purpose of the disclosure].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"12fc5e8a-008e-4998-a5b7-4d655a5c4f71","value":"1","type":"remove","operator":"="}]},{"id":"2626df8d-9b46-46bf-84fd-31653787bf3f","order":44,"text":"This use or disclosure is made at the request of the Patient. Consistent with 45 CFR § 164.508(c)(1)(iv), the statement of purpose is "at the request of the individual."","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"12fc5e8a-008e-4998-a5b7-4d655a5c4f71","value":"1","type":"add","operator":"="}]},{"id":"dd995e91-070b-4bd0-afde-65177e7448f0","order":45,"text":"EXPIRATION OF THIS AUTHORIZATION","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"b53a488d-48df-4a12-8a11-e27c31b8e5d7","order":46,"text":"This Authorization shall expire on the following date: [Expiration date].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"8c4e330a-cf2e-4547-a56b-bf0bb6b9723f","value":"date","type":"add","operator":"="}]},{"id":"2dc0384d-bd17-4ece-9999-0a5de75e94ac","order":47,"text":"This Authorization shall expire upon the occurrence of the following event: [Describe the event].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"8c4e330a-cf2e-4547-a56b-bf0bb6b9723f","value":"event","type":"add","operator":"="}]},{"id":"56ff8d7d-87c4-4a4a-af65-55e0de05bf9f","order":48,"text":"This Authorization shall remain in effect until it is revoked in writing by the Patient. The Patient understands that federal law requires an expiration date or event and that "until revoked" is a permitted expiration event.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"8c4e330a-cf2e-4547-a56b-bf0bb6b9723f","value":"revoke","type":"add","operator":"="}]},{"id":"14d00c06-f397-44f3-b2ef-d6910b76ffa6","order":49,"text":"RIGHT TO REVOKE","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"1a37aeff-9f4f-408e-9a4b-4cd27338abd7","order":50,"text":"The Patient understands that he or she has the right to revoke this Authorization at any time. A revocation must be made in writing and delivered to the disclosing party identified above under the heading "Person or Entity Authorized to Make the Disclosure." The revocation will take effect upon receipt, except to the extent that the disclosing party has already acted in reliance on this Authorization before receiving the written revocation. Revocation of this Authorization will not affect any action taken in reliance on it prior to receipt of the written revocation.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"04699086-e408-4e8f-ad94-5c090bbad849","order":51,"text":"POTENTIAL FOR REDISCLOSURE","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"628b6ff2-1448-460f-a9a1-560159360abe","order":52,"text":"The Patient understands that information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient and, once disclosed, may no longer be protected by the federal HIPAA Privacy Rule.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"0e3a552a-af84-48ec-9078-6dc7e70c447d","order":53,"text":"Prohibition on redisclosure of substance use disorder records. This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2). The federal rules prohibit you from making any further disclosure of information that identifies the Patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person, unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to investigate or prosecute any person with a substance use disorder, except as provided at §§ 2.12(c)(5) and 2.65.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"b8730f31-ff34-4cff-ae39-0e6f8e625479","value":"1","type":"add","operator":"="}]},{"id":"a9f13fa6-f51a-443c-8b2d-ddd30bba7c0a","order":54,"text":"The Patient further understands that other categories of specially protected information (such as HIV/AIDS, mental health, genetic, or reproductive health information) may be protected by state law that restricts their redisclosure even after they have been released.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"e4d1f74c-b76f-4352-a63f-600b32ff2d4b","order":55,"text":"TREATMENT, PAYMENT, ENROLLMENT, OR ELIGIBILITY NOT CONDITIONED","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"63289149-2548-4527-aa15-c7bad2ed67f6","order":56,"text":"The Patient understands that the disclosing party may not condition treatment, payment, enrollment in a health plan, or eligibility for benefits on whether the Patient signs this Authorization, except as permitted under 45 CFR § 164.508(b)(4). Signing this Authorization is voluntary.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"538518a3-e353-44ee-b178-ed41305ca5f8","order":57,"text":"RIGHT TO A COPY, RESPONSE TIME, AND FEES","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"8c657b3f-ed90-47df-8915-5b4de2a8a3c3","order":58,"text":"The Patient is entitled to receive a copy of this signed Authorization. The Patient understands that the disclosing party will act on a request for records within the time required by applicable law (generally within thirty (30) days, subject to any extension permitted by law), and that the disclosing party may charge a reasonable, cost-based fee for copies of the records provided, as permitted by 45 CFR § 164.524 and applicable state law.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"5bd45734-386a-46f1-8571-5638db8aee0e","order":59,"text":"GENERAL PROVISIONS","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"c1cefff0-4a8a-4822-8a36-a4a02e769bae","order":60,"text":"Copies. A photocopy, facsimile, or electronic copy of this Authorization shall be as valid as the original.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"85a5ecba-1605-41dc-b473-45ee1b3468f3","order":61,"text":"Electronic signature. The parties agree that this Authorization may be signed electronically and that an electronic signature shall have the same legal effect as a handwritten signature under the federal E-SIGN Act and applicable state Uniform Electronic Transactions Act.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"7457a15a-d69f-4a8e-9dcd-6a3f21b6fa4c","order":62,"text":"Understanding and language. The Patient (or authorized signer) represents that he or she has read this Authorization, or has had it read and explained, in a language he or she understands, and that all questions have been answered.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"e40128b2-5e4c-4654-9455-d69d0d45e549","order":63,"text":"Severability. If any provision of this Authorization is held to be invalid or unenforceable, the remaining provisions shall continue in full force and effect.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"37a34129-3de4-4c84-ad54-62322459ed99","order":64,"text":"Identity verification. The disclosing party may require reasonable verification of the identity and authority of the person signing or presenting this Authorization before making any disclosure.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"1409e7c6-501a-4757-bc67-98be496d5f06","order":65,"text":"Governing law. This Authorization shall be governed by, and construed in accordance with, applicable federal law and the laws of the State of [State].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"e68d3f53-b460-4cd1-8ce9-96050de0300b","order":66,"text":"ACKNOWLEDGMENT AND SIGNATURE","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"9343c241-8028-48b0-b8af-d3cbb01ff56d","order":67,"text":"The Patient (or the Patient's authorized signer) certifies that he or she has read and understands this Authorization, that it is given voluntarily, and that all questions have been answered to his or her satisfaction.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true},{"id":"044863f7-dce5-43a8-9db5-f325a29d3eb3","order":68,"text":"Signature of Patient: __________________________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"b3ff5548-f9f0-459b-b0af-cc18a6d82c95","value":"self","type":"add","operator":"="}]},{"id":"f923f62f-181b-4bd4-997c-83b954c62936","order":69,"text":"Printed name: [Patient full name] Date: ____________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"b3ff5548-f9f0-459b-b0af-cc18a6d82c95","value":"self","type":"add","operator":"="}]},{"id":"7370fee5-cc63-4aa7-8398-ab6cfb46b88e","order":70,"text":"Signature of Authorized Signer: __________________________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"b3ff5548-f9f0-459b-b0af-cc18a6d82c95","value":"self","type":"remove","operator":"="}]},{"id":"dcec1209-def8-47c4-88fc-cf0ab9b3dad8","order":71,"text":"Printed name: [Representative name] Date: ____________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"b3ff5548-f9f0-459b-b0af-cc18a6d82c95","value":"self","type":"remove","operator":"="}]},{"id":"05ae848c-cb5e-44a0-bd7a-7cb6ee524563","order":72,"text":"Authority / relationship to Patient: [Basis of authority]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"b3ff5548-f9f0-459b-b0af-cc18a6d82c95","value":"self","type":"remove","operator":"="}]},{"id":"80e8728d-b01b-46ff-9da9-53cce3970ded","order":73,"text":"Documentation of authority attached (describe): [e.g., power of attorney, letters of guardianship, letters testamentary].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"b3ff5548-f9f0-459b-b0af-cc18a6d82c95","value":"self","type":"remove","operator":"="}]},{"id":"7fc4df01-e446-4a69-9103-96e3eae5f0a0","order":74,"text":"Witness: __________________________________________ Date: ____________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"e0ae41ab-9302-4525-925e-3f22c591fcfc","value":"1","type":"add","operator":"="}]},{"id":"2b865ec6-9b32-4297-a704-0245958cf442","order":75,"text":"Printed name of witness: [Witness name]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"e0ae41ab-9302-4525-925e-3f22c591fcfc","value":"1","type":"add","operator":"="}]},{"id":"04c5d2a3-dfa4-4acd-b51c-6d6089ea356a","order":76,"text":"State of ______________________ County of ______________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"aadc4990-c1c2-48df-86fe-f5cb3f112f91","value":"1","type":"add","operator":"="}]},{"id":"2fce138b-0eab-4652-9a28-774532c20571","order":77,"text":"Subscribed and sworn to (or affirmed) before me on this ______ day of ______________, 20____, by the person whose signature appears above, proved to me on the basis of satisfactory evidence to be the person who signed this Authorization.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"aadc4990-c1c2-48df-86fe-f5cb3f112f91","value":"1","type":"add","operator":"="}]},{"id":"f0f1298a-fc7d-470b-b0fc-cf3f40c0497d","order":78,"text":"____________________________________ (Notary Public) My commission expires: ______________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"aadc4990-c1c2-48df-86fe-f5cb3f112f91","value":"1","type":"add","operator":"="}]}]