THIRD PARTY RELEASE OF INFORMATION

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you. On occasion, the patient and the Practice may want to use PHI for reasons other than treatment, payment, and health care operations, or for other purposes permitted by law. This form summarizes the anticipated use of information about you for which this authorization is required. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Specific description of the information to be used or disclosed, including the specific purpose:

Individuals who may use or disclose this information:

Individuals who may receive and use the disclosed information:

Expiration Date of this Authorization:

The above mentioned Protected Health Information may be subject to re-disclosure by the party receiving the information and may no longer be protected by the privacy rules.

To the extent that this form authorizes the sale of your Protected Health Information, such as disclosure will result in remuneration to the Practice.

By signing this form, you authorize the Practice to use and disclosure Protected Health Information about you for the reasons mentioned above. You have the right to revoke this authorization at any time, in writing, signed by you. However, such a revocation shall not affect any disclosure we have already made in reliance on your prior authorization. Submit your revocation to the Privacy Officer of the Practice.

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.

This authorization was signed by:

In front of:

Witness Name:

Date

By:

Relationship to Patient (if other than patient):

Date

Your information will be encrypted.