Authorization to Use and/or Disclose Health Information

Bakersfield Foot & Ankle Surgeons

Please correct the errors described below.

Address: 500 Old River Road STE 185, Bakersfield, CA 93311

I authorize Bakersfield Foot and Ankle Surgeons to use or disclose my health information as described below.

Authorization for Use/Disclosure of Information: I voluntarily consent to authorize Bakersfield Foot and Ankle surgeons to use or disclose my health information during the term of this Authorization to the recipient(s) that I have identified below.

Recipient: I authorize my health care information to be released to the following recipient(s).

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(Note: "at the request of the patient" is sufficient if the patient is initiating this Authorization)

Authorization Statements/Signatures

1. I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the HIPAA Privacy Rule may no longer protect the information.

2. I understand that I have a 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 a licensed Facility staff member. I understand that the revocation will not apply to information that has already been released in response to this authorization.

3. I understand that the Facility will not condition the provision of treatment or payment on the provision of this authorization.

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

(e.g. Guardian, Executor of Estate, Health Care Power of Attorney)

Distribution of copies: Original to patient's Medical Record, copy to patient.

Your information will be encrypted.