I may revoke this authorization at any time. Karina J Urquia will not electronically release my healthcare informat io n to my HealthLynked PHR. However, without this Authorization, my Dr. Karina J Urquia may, within its discretion, withhold from disclosure any of the above information as permitted or required by law.Īccess to treatment or services may not be denied to me if I decline to sign this Authorization or revoke my Authorization. Karina J Urquia has received about me from other healthcare practices, providers or facilities. Karina J Urquia may disclose any information or records (within the scope of the authorization) that Dr. I acknowledge that with this authorization Dr. I acknowledge that such healthcare information may include information regarding mental health screenings and/or treatment, including psychotherapy notes HIV/AIDS, infectious disease, sexually transmitted infection testing, screening, diagnosis, and/or treatment genetic testing history of domestic violence, child abuse, and/or family abuse and, substance/ alcohol use and treatment history. I acknowledge that such healthcare information may include the following: x rays, clinical diagnosis, histories of present illnesses, immunizations, allergies, prescription drug information, laboratory results, diagnostic screening and testing, clinical procedures, medical research, clinical trials, billing, account, and insurance information. Karina J Urquia to release any and all healthcare information about me to my HealthLynked personal health record (PHR) for my own uses and purposes. Healthlynked Authorization Release of Information
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