Authorization for Release of Information

Patient Name:

Date of Birth:

is authorized to release protected health information about the above named patient to the entities named below .The purpose is to inform the patient or others in keeping with the patient's instructions.

Entity to Receive Information.

Select each person/entity that you approve to receive information.

Voice Mail

Spouse

(provide name & phone number)

Parent

(provide name & phone number)

Email communication

(provide email address)

Description of information to be released.

Check each that can be given to person/entity on the Left in the same section.

Results of lab tests/x-rays

Financial

Medical

Breach

In order for email communication to occur, please accept the disclosure below:

I understand that if the email is not sent in an encrypted manner, there is a risk it could be accessed inappropriately. I still elect to receive email communication.

Patient Information:

I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on a signing. This authorization shall be in effect until revoked by the patient.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Personal Representative:

Date:

Description of Personal Representative Authority:

Your information will be encrypted.