Authorization to Disclose Protected Health Information (PHI)
I authorize GEM Edwards Pharmacy to use and disclose my protected health information to my prescribing physician and/or health insurance company relevant to my prescription and medication profile.
I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission.
I understand that this medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.