Authorization to Use / Disclose Protected Health Information (PHI)
Please correct the errors described below.
I understand that my records are protected under state and federal confidentiality laws. The undersigned hereby authorizes the release of protected health information described below.
I hereby authorize
To Provide Records to:
PATIENT INFORMATION I do not need to sign this authorization. Refusal to sign the authorization will not adversely affect my ability to receive health care services or reimbursement for services. The only circumstance when refusal to sign means you will not receive health care services is if the health care services represent research related treatment and the authorization is necessary to participate in the research study and receive research related treatment.
I understand I may revoke this authorization in writing at any time. If I revoke this authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. Any use or disclosure already made with your permission cannot be undone. To revoke this authorization, please send a written statement to our Medical Records Department at either of the above address and state you are revoking this authorization.
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.
Please note: Legal representative must attach copies of authorization as required by law. Examples include healthcare power of attorney, healthcare surrogate, living will or guardianship papers.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.