Authorization to Disclose Health Information

I request that my health information be disclosed:

regarding my treatment to the about named person/s.

Date/s of record to be released:

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present it to the office. I understand that the revocation will not apply to information already released. This authorization will expire 12 months from the date of my signature.

I understand that authorizing this disclosure of health information is voluntary. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. I understand the a fee may be charged.

Purvis-Moyer Foot & Ankle Center, its employees, officers and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to extend indicated and authorized herein.

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