I , give my permission to Black River Health Services, Inc to
discuss the following information.
Discuss medical history, mental health history, financial information, and compliance of treatment
with the following person(s):
I give my permission to the following person(s) to pick up prescriptions or other materials from
Black River Health Services, Inc. for myself or legal dependents (children):
I give my permission to Black River Health Services, Inc. to:
Right to Terminate or Revoke Authorization
You may revoke or terminate this authorization by submitting a written revocation to Black River Family Practice-Burgaw, Black River Health Center-Atkinson, or Maple Hill Medical Center-Maple
Hill. You should contact your primary office to terminate this authorization.
Potential for Re-Disclosure
Protected Health Information that is disclosed under this authorization may be disclosed again by
the person or organization to which it is sent. The privacy of this information may no be protected
under the Federal Privacy Regulations.
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