Authorization to Release Health Information

Patient Information

Name of Patient

Date of Birth

Address

City

State

Zip

Phone

Name of the entity

may release the following information:

Entire record

Marketing

Psychotherapy notes – if this box is checked only psychotherapy notes may be released.

Diagnostic studies (list)

Financial records

Office visit notes

Other

If other, please list

Financial compensation is received for this communication

Entity or person who will receive the information

Name

Address

City

State

Zip

Phone

Send the information electronically. Email address:

For email communication I understand that if information is not sent in an encrypted manner there is arisk it could be accessed inappropriately. I still elect to move forward to allow email communications tooccur.

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.

Signature of Patient or Personal Representative

Date

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

Revoked by patient or personal representative on

Date

How revoked:

orally (in person or via phone)

in writing (place copy in patient’s file)

Your information will be encrypted.