REDISCLOSURE. I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulations. CONDITIONING: I understand that completing this authorization form is voluntary. I realize that treatment will not be denied if I refuse to sign this form. Signature: □ Patient □ Personal Representative NOTICE THAT SERVICES ARE NOT PRIMARY CARE I understand that Xxxxx Xxxxxx, DNP is not acting as my primary care provider. I understand that even though she may address issues affecting my general health, the practice is focused on a complementary, holistic or integrative approach to medicine. It is in my best interest to also have a primary care provider to ensure that I am fully informed about all available conventional means to address any medical conditions I may have. I understand that FCIM does not provide emergency, on-call assistance. Even should Xx. Xxxxxx provide treatment for a condition, I understand this assistance does not mean she is taking primary responsibility for managing that condition, but is complementing the care I receive from my primary care provider. I understand that in addition to a primary care provider, it may be in my best interest to have appropriate specialists, such as a cardiologist if I have cardiac problems or a pediatrician if I am seeking treatment for my children. I also understand that it is my responsibility on an ongoing basis to inform FCIM of the name of and contact information for my primary care provider and treating specialists, of any diagnoses I have received, and of any treatments I have had or am now undergoing for current conditions. I also understand that it is important for me to let my primary care provider know about any recommendations/treatments performed by Xx. Xxxxxx in order to ensure that my care is properly coordinated. My primary care provider is: Name Address Phone Patient Name Patient Signature Date
REDISCLOSURE. Contractor shall not redisclose Part 2 Information to a third party unless the third party is a contract agent of Contractor helping Contractor provide services under the Service Contract and only as long as the agent further discloses Part 2 Information only back to Contractor or SBHASO.
REDISCLOSURE. Education Records may only be re-disclosed by Partner Organization to a third party with the prior written approval of the District, in accordance with this Agreement, or in compliance with FERPA and its regulations.
REDISCLOSURE. A Party has authority to redisclose Student’s educational records to the Outsider only if the Outsider does no further disclosure.
