HIPAA AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
Sierra Hearing Center may request and receive protected health information from your physician, medical group, or other healthcare organization.
The information requested may include:
• Speech Therapy Records
• Audiology Records
• Complete Medical Records
Please be aware that your medical records may contain sensitive information, including information related to behavioral or mental health.
Any information obtained through this authorization may be disclosed to and used by:
Sierra Hearing Center
900 Ryland Street
Reno, NV 89502
You have the right to revoke this authorization at any time by submitting a written revocation to Sierra Hearing Center. Any revocation will not apply to information that has already been released in response to this authorization. Unless revoked earlier, this authorization will expire after twelve months or upon another specified date, event, or condition.
Providing authorization for the disclosure of protected health information is voluntary. You are not required to sign an authorization to receive benefits or services. You have the right to inspect or obtain a copy of the information that may be used or disclosed. Please note that once information is disclosed, there is a possibility it could be re-disclosed by the recipient and may no longer be protected by applicable privacy regulations.
If you have questions regarding the disclosure of your health information, please contact:
Sierra Hearing Center
900 Ryland Street
Reno, NV 89502
(775) 329-7017