Disclosure: I understand that my healthcare provider cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.
I do hereby agree to release, indemnify and hold harmless, Big Island Healthcare, its officers, directors, employees, agents and members of its medical staff, from and against my claims against or liability incurred by it at any time, arising out of or in connection with the disclosure of medical information authorized by my pursuant to this consent. Signing this authorization may cause the health information used or disclosed pursuant to this authorization to no longer receive the protection of federal privacy laws.
This consent may be revoked at any time by notifying us, in writing, at the address above, except to the extent that the receiving facility has already taken action in reliance on it. This consent and authorization shall automatically expire six (6) months after the date of the consent, unless revoked by the patient's authorized representative prior to that time.