I hereby authorize Knospe-Lerncenter GmbH to release, disclose, and exchange my health and personal information, as described below, to and with the entity or individual named in this document.
I understand that I have the right to revoke this authorization at any time by providing written notice to Knospe-Lerncenter GmbH. Revocation will not affect any actions taken before the receipt of the revocation.
I understand that once Knospe-Lerncenter GmbH discloses my health information to the recipient, it may no longer be protected by U.S. federal and state privacy regulations and could be re-disclosed by the recipient. However, the information will still be protected under GDPR and any other applicable privacy laws.
This authorization will remain in effect until discharge from Knospe-Lerncenter GmbH, unless I request an earlier expiration date here:
Thereafter, this authorization becomes null and void. I understand that I have a right to receive a copy of this authorization.
If you have questions about this authorization or need to revoke it, please contact:
Knospe-Lerncenter GmbH Georgstr 2, 31675 Bückeburg, Deutschland Phone: +49 5722 9098399 Email: [email protected]
I have read and understood this authorization form. I understand that I have a right to receive a copy of this authorization.
By signing below, I agree to the terms and conditions outlined above.
