to use or disclose protected health information listed in the Description section below to the Entity or Person listed in the Receiving Entity section for the following patient:
Receiving Entity: Please check the boxes for those entities or persons you wish to get the described information about you.
Description of information to be given to checked Entity or Person.
Any treating facility to receive PHI by unencrypted email
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The purpose of this authorization is to meet the patient's request for information disclosures and uses.
The authorization shall be enforce until revoked by the patient or
This practice will verify the identify of any entity requesting protected health information. Verification information may include:
I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. I understand that I have the right to revoke this authorization at any time by sending a written notification to the address listed at the top of this form. I understand that a revocation is not effective in cases where the information has already been used or 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.
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.
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Your information will be encrypted.
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