Authorization to Use and Disclose Health Care Information

Susannah Graven LMT

940 Town Centre Drive, Suite B, Medford OR 97504 | (541) 772-5939

First Name

Last Name

Date of Birth

I authorize my massage therapist Susannah Graven to disclose my health care information with the following health care providers and/or insurance companies:

Enter first and last name to agree.

Health care provider/Insurance company name(s):

Health care provider/insurance company address:

The following information may be disclosed (check all that apply):

All health care information in my chart.

Only health care information relating to the injury, illness, or treatment identified below.

Only health care information for the date or time period identified below.

Including information regarding HIV, STD, mental health, and drug or alcohol abuse.

Please identify specific injury, illness, or treatment and/or specific dates or time periods for sharing health care information in the box below:

I give my authorization to release health care information for the following purpose (check all that apply):

To share information with my health care team in an attempt to coordinate care.

To obtain payment of care expenses I have incurred for my treatments.

This authorization expires on:

(no longer than 1 year from the date signed)

I understand that I may refuse to sign this authorization.

I may also revoke this authorization at any time by writing a letter to my massage therapist.

I understand that once my health care information is disclosed, the recipient may redisclose the information and it may no longer be protected by HIPAA or state privacy laws.

I also understand my obtaining care cannot be conditioned on my signing this release.

Signature:

By typing your name in this box you agree to the above declaration

Date Signed

Your information will be encrypted.