Authorization to Disclose Protected Health Information (PHI)

Patients 18 Years or Older

Please correct the errors described below.

I authorize the following people to receive Protected Health Information:

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  • I understand that this authorization may be revoked by me at any time except to the extent that action has been taken in reliance upon it.
  • The information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer protected.
  • I have read the above and authorize the disclosure of the protected health information.

This release expires 1 year from date of signature.

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.

Your information will be encrypted.

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