I hereby authorize physicians, hospitals, and other medical personnel to disclose protected health information about me to Christian Health Aid/Century Health Alliance for the purpose of determining eligibility and negotiating payment.

UNLESS YOU SIGN HERE, NO INFORMATION ABOUT ALCOHOL/SUBSTANCE ABUSE, HIV/AIDS, OR MENTAL HEALTH WILL BE DISCLOSED:

1. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.
2. I may revoke this authorization by notifying the provider/hospital/medical personnel in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
3. This authorization will expire in one (1) year unless revoked in writing.