Second Office or Facility Address: [box to provide an answer] Second Office Phone Number: [box to provide an answer] 3. Third Licensed Health Care Provider (Optional) [Checkbox] Not Applicable Third Provider Name: [box to provide an answer] Third Office or Facility Address: [box to provide an answer] Third Office Phone Number: [box to provide an answer] This authorization shall remain in effect until my eligibility for RTS paratransit service is finally determined or 60 days from the date of the authorization, whichever occurs first. I acknowledge that I have the right to revoke this authorization at any time by sending written notification to the persons named above. I understand that the revocation of this authorization is not effective to the extent that the name provider has relied upon it for the use or disclosure of the Protected Health Information prior to receiving my written revocation notice. I understand that any Protected Health Information disclosed pursuant to this Authorization to an individual or entity that is not covered by state and federal privacy laws and regulations may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I acknowledge that the named persons will not condition my treatment, payment,
Second Office or Facility Address: [box to provide an answer] Second Office Phone Number: [box to provide an answer] 3. Third Licensed Health Care Provider (Optional) [Checkbox] Not Applicable Third Provider Name: [box to provide an answer] Third Office or Facility Address: [box to provide an answer] Third Office Phone Number: [box to provide an answer] This authorization shall remain in effect until my eligibility for RTS paratransit service is finally determined or 60 days from the date of the authorization, whichever occurs first. I acknowledge that I have the right to revoke this authorization at any time by sending written notification to the persons named above. I understand that the revocation of this authorization is not effective to the extent that the name provider has relied upon it for the use or disclosure of the Protected Health Information prior to receiving my written revocation notice. I understand that any Protected Health Information disclosed pursuant to this Authorization to an individual or entity that is not covered by state and federal privacy laws and regulations may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I acknowledge that the named persons will not condition my treatment, payment,
ExhibitsOnly_01-14_LargeFont_ParatransitPlan.docx