When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the Federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the Rothman Institute, 925 Chestnut Street, 5 th Floor, Philadelphia, PA 19107, Attention: Medical Records Requests.
I understand that there is a fee associated with requests for records. This fee will be invoiced to the requestor and is required to be paid prior to the request being processed. Please allow 7-10 business days to process your requests after payment has been received.
By clicking the submit button below, I acknowledge that I have read this authorization and understand its terms. I also acknowledge that I am lawfully permitted to request the information listed above as well as authorize Rothman Institute, its employees and agents to process this request.