Authorization To Release Healthcare Information

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Patient Information

Healthcare Provider / Entity Information

The Purpose Of Release

Information To Be Released

This Consent is subject at any time, except to the extent that action has been taken in reliance on the patient's consent.

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.

NOTE TO RECEIVER (Notice Prohibiting Redisclosure): This information has been disclosed to you from records protected by federal confidentiality rules(42 CFR Part2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of rht person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of this information to criminality investigate or prosecute any alcohol or drug abuse patient.

Your information will be encrypted.