Authorization to Use and Disclose Health Care Information

Susannah Graven LMT

Please correct the errors described below.
(type your first and last name here)

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

(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.

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

After you click on the submit button below, you will be returned to this page where you can click here to return to the MEDICAL PRACTICE FORMS page to complete your forms.

Your information will be encrypted.