Release of Information Form

Summit Digestive & Liver Disease Specialists

Please correct the errors described below.

AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION

PATIENT

FROM

PROVIDE TO

Who do you want the patient information to be sent to?

*Sending information by Fax increases privacy risks, as they involve increased risk of accidental disclosure. Information sent electronically may also be vulnerable to cyber-attack.

REQUESTED INFORMATION

Please check or describe the health information that you would like disclosed:

PURPOSE

Why are you requesting this disclosure?

VALIDITY

Revocation: An authorization may be revoked at any time by written notice to Summit Digestive & Liver Disease Specialists. Revocation is not effective until notice is received and is not effective regarding disclosures made before revocation and where authorization was obtained as a condition of insurance coverage.

PATIENT RIGHTS

I understand that: (1) I have a right to receive a copy of this signed authorization upon request; (2) I have a right to refuse to sign this authorization – Summit Digestive & Liver Disease Specialists may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits on a decision to sign this form; and (3) I have a right to inspect or copy my health information. I may arrange to inspect or copy information maintained by Summit Digestive & Liver Disease Specialists by contacting Health Information Management. I may be charged a reasonable fee for copying costs.

REQUESTOR

I authorize the disclosure of health information described above. Information released under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by Federal privacy standards, including HIPAA and the Privacy Act of 1974. A photo copy/fax of this form is as valid as the original.

By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

OFFICE USE ONLY

Your information will be encrypted.

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