Aforementioned personal health information will be shared with:
Karen Meckstroth, MD, MPH
University of California, San Francisco (UCSF)
Women's Options Center
2356 Sutter St.
San Francisco, CA 94143-1648
Phone: (415) 353-7003
Fax: (415) 353-9605
For the purposes of research as described in the attached Consent Form, this authorization is in effect until the research ends and all required study monitoring is over.
I understand that by signing this authorization:
I authorize the use or disclosure of my individually identifiable health information as described above for the purpose listed.
I have the right to withdraw permission for the release of my information. If I sign this authorization to use or disclose information, I can revoke that authorization at any time. The revocation must be made in writing and will not affect information that has already been used or disclosed.
I have the right to receive a copy of this authorization.
I am signing this authorization voluntarily and treatment, payment, or my eligibility for benefits will not be affected if I do not sign this authorization.
I further understand that a person to whom records and information are disclosed pursuant to this authorization may not further use or disclose the medical information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law.