Authorization for Release of Protected Health Information

I have read and understand the following: 

  • I may revoke this authorization at any time by submitting a written request to the Privacy Officer at or by mail at Privacy Officer, 607 Dewey Ave NW, Ste 300, Grand Rapids, MI 49504.

  • Alliance may disclose or be allowed by law to refuse to permit access or allow disclosure of part of all of my medical record. If that happens, Provider will notify me in writing.

  • I may refuse to sign this authorization. If I refuse to sign this authorization, my treatment, payment, health plan enrollment, or eligibility benefits will not be affected.

  • Information released on this authorization, if re-disclosed by the recipient, is no longer protected by Provider.