Authorization to Disclose Protected Health Information (PHI)

Patients 18 Years or Older

Please correct the errors described below.

Patient Legal Name:

Date of Birth:

Phone #:

Address:

City:

State:

Zip:

I authorize the following people to receive Protected Health Information:

Add another authorized person

I authorize the following protected health information to be disclosed:

Well visit chart notes

Sick visit chart notes

Laboratory results

X-Ray reports

Medical instructions or advice

Prescription drug information

Drug abuse

Alcohol abuse

Sexual activity or HIV/AIDS or STDs

Psychological or psychiatric conditions, including psychotherapy notes

Other

If Other, Please Specify:

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.

Signature of Patient:

Date:

Your information will be encrypted.

Electronic signature

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I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

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