Medical Records/Information

Name:

D.O.B:

Social Security Number:

Address:

Phone#

I, the patient named above, hereby authorize the use and disclosure of my individually identifiable health information as described below.

Persons/organizations authorized to use or disclose my information (address and phone):

Address:

Phone#:

Specific description of the information to be used or disclosed (including date(s)):

Description of each purpose of the use or disclosure of my patient information: (Note: If the release of information is requested by the patient, please insert the request of the here if the patient does not provide a statement of purpose):

This authorization shall be effective until the records I have requested have been delivered to the above-referenced provider, at which time this authorization will expire.

I understand that I have the right to revoke this authorization at any time by giving you written notice. I understand that, even if I revoke my authorization, it will not be effective to the extent you have relied on it to use or disclosure my protected health information. I understand that your Notice of Privacy Practices may discuss my right to revoke and my other rights. I also understand that the above entities may not condition treatment or my payment for treatment on obtaining this authorization from me.

I understand that this authorization is voluntary. I understand that the information disclosed under this Authorization could potentially be re-disclosed by the person(s) receiving the information, and may no longer be subject to the privacy protections provided to me under the privacy laws that protect health information.

I have read (or had read to me) the above authorization and I understand my rights with regard to my protected health information. I have been provided with a copy of the authorization.