4. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal privacy rules. 5. I understand that any uses or releases already made with my consent cannot be taken back. 6. I understand that I may request a copy of this signed consent. 7. I understand that this consent will expire at the end of MIHP services unless I cancel it before then. I have read the above or it has been read and explained to me. I understand that I may receive MIHP services without consenting to release my protected health information. I DO consent to the release of protected health information as specified in this form. I DO NOT consent to the release of protected health information as specified in this form. _______________________________________ ____________________________________ Beneficiary Name (Print) Legal Representative Name if applicable (Print) ________________________________________ Legal Representative Relationship to Beneficiary ________________________________________ _____________________________ Signature of Beneficiary or Legal Representative Date ________________________________________ ____________________________ Signature of MIHP RN or SW Date
4. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal privacy rules. 5. I understand that any uses or releases already made with my consent cannot be taken back. 6. I understand that I may request a copy of this signed consent. 7. I understand that this consent will expire at the end of MIHP services unless I cancel it before then. I have read the above or it has been read and explained to me. I understand that I may receive MIHP services without consenting to release my protected health information. I DO consent to the release of protected health information as specified in this form. I DO NOT consent to the release of protected health information as specified in this form. _______________________________________ ____________________________________ Beneficiary Name (Print) Legal Representative Name if applicable (Print) ________________________________________ Legal Representative Relationship to Beneficiary ________________________________________ _____________________________ Signature of Beneficiary or Legal Representative Date ________________________________________ ____________________________ Signature of MIHP RN or SW Date