Authorization to Release Health Information

Patient Name:______Social Security Number:______

I Authorize(Provider’s name)______at (Organization)______to release the above named individual’s health information to ______with the information as indicated below:

Please indicate the information to be disclosed, including dates where appropriate:

Problem List

Medication List

Patient Account Statement/Billing Records

Entire Record

Other:______

From (mm/dd/yyyy) ______to (mm/dd/yyyy) ______

I understand that the information in my health record may include information relating to sexually transmitted diseases, acquired immunodeficiency syndromes like AIDS, or human immunodeficiency viruses like HIV. It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.

This information may be disclosed to and used by the following individual or organization:

Name: ______

Address: ______

Phone: ______Fax: ______

I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to our Practice Administer. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy Unless otherwise revoked, this authorization will expire on the following date, event, or condition: ______. If I fail to specify an expiration date, event, or condition, this authorization will expire in 12 months.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CRF 164.524 of the Federal Register Rules and Regulations. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by the federal confidentiality rules. If I have questions about disclosure or my health information, I can contact the Practice Administrator.

______

Signature of Patient or Legal RepresentativeDate

______

If signed by Legal Representative, Relationship to PatientSignature of Witness

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