Patient Rights: As a patient, you have the right to access, copy or inspect your protected health information (PHI) in accordance with federal law. You may also have the right to request an amendment to your PHI, or request that we restrict the use and disclosure of it. These rights are further described in our Notice of Privacy Practices and in other District policies, which you may have upon request. I understand that I have the right to revoke this Authorization at any time except to the extent that CCFR has already acted in reliance on the Authorization. To revoke this Authorization, I understand that I must do so by written request to the District Privacy Officer.

I understand that information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient and no longer subject to privacy protections by law. I understand that my written authorization is not required to use my PHI for treatment, payment and health care operations. I understand that I have the right to inspect and copy my PHI. The Authorization is being requested for the following purposes: By signing this form, I hereby authorize and direct the use or disclosure by Clark-Cowlitz Fire Rescue of certain medical information (PHI) pertaining to my health, my health care, or me. I acknowledge that I have read the provisions in this form and that I have the right to refuse to sign this form. I understand and agree to its terms.