I understand that Arcadia Radiology Medical Group will not condition treatment or eligibility for care on my providing this authorization except if such care
(1) Research related or (2) provided solely for the purpose of creating Protected Health Information for disclosure to a third party.
I understand that information disclosed by this authorization, except for Alcohol and Drug Abuse as defined in 42 CFR Part 2, may be subject to
redisclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act Privacy Rule [45 CFR Part
164] , and the Privacy Act of 1974 [5 USC 552a].