Disclosure by Medical Liaison for Certain Purposes Sample Clauses

Disclosure by Medical Liaison for Certain Purposes. I authorize the Medical Services Team and USA BMX to use and disclose my Health Information in their possession to the following: (1) physicians, health care providers, hospitals, state and local health departments, and other health care facilities or medical providers for purposes of my assessment, care and treatment; and/or (2) outside experts, physicians or consultants retained by USA BMX, for purposes of safety and quality assurance/improvement and making assessments and recommendations related to quality or safety. I understand the Medical Services Team coordinators and consulting physicians are not direct treatment providers; they are present at the Event grounds to facilitate the sharing of information. I understand that I have the right to revoke this Authorization in writing at any time by notifying, as applicable, the disclosing Health Care Provider, Medical Services Team and/or USA BMX. I understand that the revocation is only effective after it is received. I understand that any use or disclosure made prior to the revocation in reliance on this Authorization will not be affected by a subsequently received revocation.

Disclosure by Medical Liaison for Certain Purposes. I authorize the Rodeo Committee Medical Services Team to use and disclose my Health Information in their possession to the following: (1) physicians, health care providers, hospitals, state and local health departments, and other health care facilities or medical providers for purposes of my assessment, care and treatment; and/or (2) PRCA/WPRA, and outside experts, physicians or consultants retained by any of them, for purposes of safety and quality assurance/improvement and making assessments and recommendations related to quality or safety. I understand the Rodeo Committee Medical Services Team coordinators and consulting physicians are not direct treatment providers; they are present at the rodeo grounds to facilitate the sharing ofinformation. I understand that I have the right to revoke this Authorization in writing at any time by notifying, as applicable, the disclosing Health Care Provider and/or Rodeo Committee Medical Services Team. I understand that the revocation is only effective after it is received. I understand that any use or disclosure made prior to the revocation in reliance on this Authorization will not be affected by a subsequently received revocation. I understand that once Health Information is disclosed pursuant to this Authorization, it may be re-disclosed by the recipient, and federal or applicable state and provincial law might not protect it. I understand a health care provider, hospital or health facility may not condition my treatment on whether this Authorization is signed. I understand that PRCA/WPRA rules and policies will govern whether I may participate in any PRCA-sanctioned event if I choose to revoke this Authorization. I have read this Authorization, I understand what it says, and any questions of mine have been answered to my satisfaction. I understand that I am entitled to receive a copy of this Authorization, and I allow a photocopy to be deemed valid as a signed original. Signature: