Medical Consent Acknowledgement

Authorization for Disclosure of Patient Medical Information

By signing the Authorization for Disclosure of Patient Medical Information (“Authorization”) I am now submitting, I understand that I am giving Gables Medical Review permission to obtain and use protected private health information. I understand myprotected health information may include mental health, substance abuse (e.g., drugs, alcohol), HIV/AIDS status information, and diagnostic and treatment records. I understand that I may revoke this Authorization at any time by notifying Gables Medical Review in writing. I understand that any revocation will not affect disclosures made prior to the revocation being received and processed. I understand the information I disclose may be subject to redisclosure may be subject to redisclosure by Gables Medical Review to facilitate the services Gables Medical Review provides and that at that point it may no longer protected by federal or state privacy laws. I understand that this Authorization will remain in effect during the period of my subscription with Gables Medical Review and will be auto-renewed along with my subscription. I understand that signing this Authorization is voluntary and that I may refuse to sign it. I authorize the use of a copy (including electronic copy) of the Authorization to be used for the disclosure of the information described therein. I understand that I may inspect and receive a copy of the protected health information disclosed pursuant to this Authorization.In the event that the facility is unable to accommodate an electronic delivery as requested, I authorize the use of an alternative delivery method to be requested, such as a paper copy. I understand there is some risk that a third party could use my protected health information without my consent when receiving unencrypted electronic media or email. I will not hold Gables Medical Review or its affiliates responsible for unauthorized access to the protected health information contained in this format, or any risks potentially introduced to my computer/device when receiving protected health information in electronic format or email. I hereby release Gables Medical Review from any and all liability related to (i) their reliance upon this Authorization; (ii) the release of information pursuant to this Authorization; or (iii) the transmission of information in order to facilitate the services provided by Gables Medical Review. Furthermore, Gables Medical Review is not responsible or liable for any direct, indirect, incidental, consequential, special, exemplary, punitive or other damage related to this authorization of release and/or transmission of protected health information.

By clicking “submit” I acknowledge that I have carefully read, understand and agree to the above terms and conditions as well as those listed on the Authorization for Disclosure of Patient Medical Information form I am hereby submitting.

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