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NOTICE: Walk-In Lab and other health organizations are required to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.
MY RIGHTS: I understand this authorization is voluntary. Treatment may not be conditioned on signing this authorization except if the authorization is for: a) conducting research-related treatment and b) creating health information to provide to a third party. I may revoke this authorization at any time, provided I do so in writing and submit to Walk-In Lab, P.O. Box 999, Madisonville, LA 70447. The revocation will take effect when Walk-In Lab receives it. I am entitled to receive a copy of this Authorization.
My submission of this form represents my signature.
Expiration of this Authorization
(expires in 12 months if date is not indicated)
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