Records Released To Jenny Welham MD LLC 1401 S. Beretania St. Ste. 370 Honolulu, HI 96814 Fax: (808) 947-9987
I authorize the third party named in the above section to disclose the protected health information about myself (or the patient) as described above. I understand:
1. This authorization expires 180 days from the date of my signature unless I specify otherwise.
2. I may revoke this authorization at any time by notifying Jenny Welham MD LLC in writing. If I revoke the authorization, I understand that it will have no effect on actions Jenny Welham MD LLC took in good faith before receiving the revocation.
3. The information released may contain information related to AIDS or HIV infection drug or alcohol abuse behavioral health or psychiatric care, except for psychotherapy notes.
4. Jenny Welham MD LLC may not withhold treatment or payment based on my completion of this form.
5. Jenny Welham MD LLC reserves the right to verify my identity or guardianship.
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.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.