Confidential Authorization for Release of Medical Records

Please correct the errors described below.

Confidential information to, from, or with the following persons/organization:

Expiration Date to be One Year From Completed Form

Note: regular email is not secure and it is possible to compromise your PHI unless you are using an email that allows you to encrypt your email correspondence.

You have the right to revoke this authorization in writing at any time by sending such written notification to our office address. However, your revocation will not be effective to the extent that we have taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that information used or disclosed pursuant to the authorization maybe subject to re-disclosure by the recipient of the information and no longer protected by the HIPAA Privacy Rule.

By initialing this form you are consenting to have your records disclosed, received or exchanged to the entity listed above

You have a right to receive a copy of signed authorizations upon request.

Your information will be encrypted.