EB NUTRITION, LLC

301-231-0026

PATIENT RECORD OF DISCLOSURES

In general, the HIPPA privacy rule gives individuals the right to request a restriction on uses and disclosures of their Protected Health Information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.

I wish to be contacted in the following manner (check all that apply):

□ Home Telephone ______□ Written Communication

□ Ok to leave message with detailed information □ Ok to mail to my home address

□ Leave message with call back number only □ Ok to mail to my work/ office address

□ Ok to fax to this number

□ Work Telephone ______□ Other ______

□ Ok to leave message with detailed information ______

□ Leave message with call back number only ______

______

Patient Signature Date

______

Print NameDate of Birth

The Privacy Rule generally requires health care providers to take reasonable steps to limit the use or disclosure of and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual. Healthcare entities must keep records of PHI disclosures. Information provided below, if completed properly, will constitute an adequate record.

NOTE: Uses and disclosures may be permitted without prior consent in an emergency.

Record of Disclosures of Protected Health Information

Date / Address/ Fax # of Disclosure / Purpose/ Description / Signature

PATIENT REGISTRATION – Please Print Clearly

How would you like to be addressed? ______

LAST NAME / FIRST / M.I. / SEX / DOB / SSN
ADDRESS / CITY / STATE / ZIP / HOME#
OCCUPATION (IF CHILD, PARENT) / MARITAL STATUS S M D W / WORK#
BUSINESS NAME / BUSINESS ADDRESS / FAX#
SPOUSE NAME / SPOUSE EMPLOYER / SPOUSE#
EMERGENCY CONTACT / ADDRESS / PHONE#
WHO REFERRED YOU? / EMAIL / PHARMACY#

MINORS

PARENT’S NAME / PARENT ADDRESS / PARENT#

CURRENT / RECENT HEALTH CARE PROVIDERS – List Primary Care Physician First

NAME OF PROVIDER / ADDRESS / PHONE NUMBER

RELEASE OF INFORMATION

I give permission for Elizabeth Blumberg of EB Nutrition to:

_____ RECEIVE my medical records from another physician/facility

_____ SEND my medical records to another physician/ facility

Concerning the following named person:

Patient Name: ______

Date of Birth: ______

Street Address:______

City: ______State: _____ Zip Code: ______

Authorized records released from: Please fill in the complete name, address and phone number of the physician/ facility in which we are receiving or sending you medical records.

Briefly describe the purpose or need for release: ______

This authorization will remain in effect until: ______

This authorization will be effective for medical records generated to the date of signature.

I understand I may revoke this authorization in writing at any time.

Signature of Patient: ______Date: ______

(If signed by other person other than patient, state relationship to patient)

Legal Authority: ______Parent: ______Legal Guardian: ______