5. I understand that this information may include information relating to specific laboratory tests of HIV infection (Human Immunodeficiency Virus, the causative agent of AIDS) or the diagnosis of Acquired Immune Deficiency Syndrome (AIDS) or AIDS related conditions; treatment for drug or alcohol abuse; mental or behavioral health or psychiatric care, excluding psychotherapy notes.
6. I understand that St. Luke’s Health may charge a fee for the costs associated with processing this request.
7. St. Luke’s Health may deny this request to inspect and copy health information in certain limited circumstances, which are described in separate policies. If you are denied access, you may request that the denial be reviewed. Another licensed health care professional chosen by St. Luke’s Health will review your request and the denial. The person conducting the review will not be the person who denied the request. St. Luke’s Health will comply with the outcome of the review.
8. This authorization is given freely with the understanding that:
a) I may revoke this authorization at any time, except where information has already been released.
b) The revocation must be in writing and a form is available from the medical record department.
c) This authorization will expire no more than one year from date of signature unless otherwise specified;
d) St. Luke’s Health may not condition treatment or payment upon obtaining this authorization.
e) A photocopy or fax of this authorization is as valid as the original.
f) Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and is no longer protected.