I authorize: To use and disclose a copy of the specific health information described below:

Consisting of:

✓ History and physical examinations
✓ Consultation reports
✓ Laboratory reports
✓ Operative reports
✓ Discharge summary
✓ X-ray/Diagnostic images
✓ Other, specify below.

To: Dra. Silvia Avilés, CECIP Centro de Cirugía Plástica y Especialidades en República Dominicana Santo Domingo.

If the information to be disclosed contains any of the types of records or information listed below, additional laws regarding the use and disclosure of the information may apply. I understand and accept that this information will be disclosed, so I will proceed to fill in the following fields with my data as a sign of agreement.

This authorization is voluntary and you may refuse to sign this authorization. Refusal to sign this authorization will affect your ability to participate in this care coordination program and failure to disclose any of the above conditions may result in cancellation of the surgery.

You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. Any use or disclosure that has already been made with your permission cannot be undone.

I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer protected by federal law. However, I also understand that federal or state law may restrict the release of HIV/AIDS information, mental health information, drug/alcohol diagnosis, treatment, or referral information.

I understand that my health information may be shared with health care providers, nurse case managers, health advocates, and other professionals who have currently been or will be involved in my care in order to better coordinate my care.