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Michael K. Lloyd, M.D. Inc.

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

Completion of this document authorizes the disclosure and/or use of health information, about you.
I request and authorize:
Michael K. Lloyd, M.D. Inc.
460 Greenfield Ave. #3 Hanford, CA 93230
PH: 559.584.5770
FAX: 888.774.0477
This request & authorization applies to:
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• I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment or payment or eligibility for benefits. • I may inspect or obtain a copy of the health information that I am being asked to allow the use or disclosure of.
• I may revoke this authorization at any time, but I must do so in writing and submit it to the following address: Michael K. Lloyd, M.D., 460 Greenfield Ave. Ste #3, Hanford, CA 93230
• My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this authorization. • I have a right to and will receive a copy of this authorization.
• Information disclosed pursuant to this authorization could be re-disclosed by the recipient. Such re-disclosure is in some cases not protected by California law and may no longer be protected by Federal confidentiality law (HIPAA).

Signature of Patient or Patient Representative / Responsible Party

(This authorization will expire in 6 months unless otherwise indicated)
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By clicking Accept & Sign I understand and agree that this is a legal representation of my signature.
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