Summit Digestive & Liver Disease Specialists

Authorization Form for Release of Confidential Health Information

Please correct the errors described below.

The following information contained in the patient record of


The following information is authorized for release for the treatment dates:


I understand that I have the right to inspect and copy the formation I have authorized to be disclosed by this authorization. In the event I refused to authorize the release of the above-described information, I understand that it will not be disclosed, except as provided by law.

I understand that the practice may not condition treatment on whether I sign this authorization, except when the provision of health care is solely for the purpose of creating protected health information for disclosure to a third party.

I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by law.

I understand that this authorization is valid until it expires, unless revoked before that.


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.