Authorization for Disclosure of Health Information

Please correct the errors described below.

I authorize the use or disclosure of the above-named individual health information as described below:

To:

Family Practice Associates PC.

433 Summit Blvd Suite 201

Broomfield, CO. 80021

The type and amount of information to be used or disclosed is as follows: (include dates where appropriate).

This information may be used by the following individual or organization.

Please, no CD's or digital records

This authorization may be cancelled in writing at any time. A cancellation will not change release s that happened before the cancellation. Family Practice Associates, PC, will not restrict treatment if I choose to not to sign this authorization.

A photocopy/fax of this authorization will be treated in the same way as the original. Family Practice Associates, PC, record s may include records that were received from other organizations. If these records have been used by Family Practice Associates, PC, and filed in the records Family Practice Associates, PC, maintains for you, these records may be released with your Family Practice Associates, PC, records. Family Practice Associates, PC, cannot prevent redisclosure of your information by person or organization who received your records under this authorization, and that information may not be covered by state and federal privacy protections after it is released.

By signing this authorization, you release Family Practice Associates, PC, from all liability resulting from redisclosure by the recipient.

Your signature indicates that you have read and understand this form and authorize release of your information as described above.

(attach document)

Your information will be encrypted.

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