Authorization to Release Health Information

Please correct the errors described below.

Patient Information

Financial compensation is received for this communication

Entity or person who will receive the information

This authorization shall be in effect until the information has been forwarded as requested or until the course of treatment is complete.

Patient Rights:

  • I have the right to revoke this authorization at any time by contacting our office.
  • I may inspect or copy the protected health information to be disclosed as described in this document
  • Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
  • Information used or disclosed as a result of this authorization may be subject to re disclosure by the recipient and may no longer be protected by federal or state law.
  • I may refuse to sign this authorization and that my treatment will not be conditioned on signing
  • I understand released information may include a communicable disease diagnosis such as HIV.

This authorization will remain 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.

Description of Personal Representative’s Authority (attach necessary documentation)

Your information will be encrypted.