Additional uses for which I must give my authorization:


I understand that Metroplex Women’s Clinic (MWC)/Metroplex Mobile Pregnancy Clinic (MMPC) may use my Protected Health Information for the following reasons: treatment, healthcare operations, as business associates, to contact you and as required by state or federal law. (I may opt out of this authorization) Special authorization is required.


I understand that I may revoke this authorization at any time by notifying MWC/MMPC in writing. However, if I choose to do so, I understand that my revocation will not affect any actions taken by MWC/MMPC before receiving my revocation.


MWC/MMPC reserve the right to change the Notice of Privacy Practices as necessary. The most current Notice will be placed on display in the center at all times.