Record Release Form

Patient Authorization for Use and Disclosure of PHI for Purposes Requested by the Practice

Please correct the errors described below.

The purpose(s) is/are provided so that I can make an informed decision whether to allow release of the information.

5. I understand that I do not have to sign this authorization in order to receive treatment from Patrick A. Wegman, M.D.

6. I have the right to refuse to sign this authorization.

7. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule.

8. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the Privacy Officer at:

Patrick A. Wegman, II, Practice Manager
802 W. King Suite H
Owosso, Michigan 48867

Your information will be encrypted.

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