Family Authorization to release Protected Health Information

By authorizing the listed people below, they will have access to any and all of my health information, up to an including HIV, alcohol, and psychiatric records. IDCTC affiliates are permitted to share my medical information with them, including test results, appointment reminders and information disclosed during office visits.

Persons (Other than physicians) authorized to receive my medical information:

I understand and direct this authorization will remain in effect until it is revoked by me (the patient) in writing.

HIPAA

This organization complies with all HIPAA and other federal privacy regulations. A notice of privacy policies is available upon request. I acknowledge by signature below that I have been made aware of my right to review or obtain a copy of the policies.

NOTICE OF HEALTHCARE INFORMATION:

All patient records remain the property of this practice. Records are centralized and my be accessed by medical providers or employees as necessary function of their role within the organization. The organization does not release patient unless necessary for the purpose of medical treatment, obtaining payment or supporting the day-to-day health care operations of the practice. Patient signature below provides your consent to use and disclose my health information in accordance with the above statement.

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.