Authorization for Release of Protected Health Information

Telephone: 772-348-0303
Fax: 772-348-0307

Section A: Will the Protected Health Information (PHI) be created or used for research and include treatment of the patient? If yes, complete the Authorization for Research Form. If no, proceed to Section B.

Section B: Required for all Authorizations for Release of PHI or Right to Access

Patient Name

Birth Date

Social Security No.

(optional)

Patient’s Address

Requestor’s Name/Phone Number

(if patient is not the requestor)

PHI Recipient Name

Address/City/State/Zip

Phone Number

Fax Number

PHI Sender Name

Address/City/State/Zip

Phone Number

Fax Number

This authorization will expire on the following: (Fill in the Date or the Event, but not both.)

Date

Event

Purpose of Disclosure

Is this request for psychotherapy notes?

Yes, then this is the only item you may request on this authorization.

No, then you may check as many items below as you need.

If other, please specify.

Kindly indicate date(s) for all items selected.

I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results or AIDS information.

If not, applicable, check here.

I understand that:

I may refuse to sign this authorization and my treatment will not be conditioned upon signature of this authorization (except for non-health related services such as pre-employment testing, life insurance exams, or drug screenings).
I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices.
If the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be re-disclosed.
I understand that I may see and obtain a copy the information described on this form, for a reasonable copy fee, if I ask for it.
I will receive a copy of this form after I sign it.

Section C: Signatures

I have read the above and authorize the disclosure of the protected health information as stated.

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.

Signature of Patient/Guardian/Patient Representative

Date

Name of Patient’s Representative

Relationship to Patient

Your information will be encrypted.