<p>Protected Health Information (PHI) may include information/documents regarding medical treatment
of the patient including, but not limited to, diagnosis, procedures, treatment plans, appointments and test
results; account and billing information including, but not limited to, account balances, payments and
payment arrangements, insurance claims status, and third party financing.
</p><p>I understand that the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and its
implementing regulations govern the terms of this Authorization. I understand that I have the right to revoke
this Authorization, at any time compliance with the request set forth herein, provided that the revocation is
in writing. I further understand that additional information relating to the exceptions, the right to revoke and
a description of how I may revoke this Authorization is set forth in ANR Notice of Privacy Practices.
</p><p>This authorization expires when I am no longer a patient in this practice or have revoked this authorization.
</p><p>I certify that the information provided is correct to the best of my knowledge. I have received a copy of the
Privacy Practice Notice.&nbsp;<br></p>