Fuller Living Authorization for Release of Information

(your first and last name)

hereby voluntarily authorize the disclosure of information from my health record.

The information is to be disclosed by:

(Name of Facility)

street or mailing address:

City/State/Zip code

phone number:

Fax Number:

And is to be provided to:

(name of person/organization/facility)

STREET OR MAILING ADDRESS

City/State/Zip code:

Phone number:

Fax Number:

The purpose or need for this disclosure is:

Further Medical Care Personal Use Attorney Insurance School Disability Research Health information exchange Other

If other, please specify:

Revocation:

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.

Expiration:

Unless sooner revoked, this authorization expires 6 months from the date of this authorization.

Conditions:

I further understand that this entity will not condition my treatment on whether I give authorization for the requested disclosure.

Form of Disclosure:

If you desire, you may limit the disclosure to one of the following methods:

Verbal only Paper or electronic No preference

Birthday of client

Redisclsoure:

I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization may be redisclosed by the recipiet and the protected health information will no longer be protected by the HIPAA privacy regulations, unless a State law applies that is more strict than HIPAA and provides additional privacy protection.

Electronic Signature of Client (or guardian):

Date:

**If you are signing as a personal representative of an individual, please describe your authority to act for this individual (power of attorney, healthcare surrogate, etc) , describe here:

Your information will be encrypted.