I hereby authorize Sidra Medicine to disclose my individually identifiable health information as described below.
I understand that this authorization is voluntary and I may refuse to sign this authorization. I further understand that my healthcare and the payment of my healthcare will not be affected if I do not sign this form.
I further understand that I may revoke this authorization at any time by notifying, in writing, the Sidra Medicine facility where this authorization is being signed. I also understand the revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any releases made prior to the receipt of the written revocation.
I understand the record might not be complete, if it is a recent visit, and additional documentation could be added after submitting this request.