Authorization to Release Protected Health Information (PHI)

Authorization to Release Protected Health Information (PHI)
Important Note: You are not required to complete this form electronically. If you would prefer a paper copy to complete, please call us at (919) 600-4906.

Your PROTECTED HEALTH INFORMATION (PHI) includes any individually identifiable health information (e.g., medical records) that is transmitted or maintained in any form (e.g., orally, electronically, by mail).
Patient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
Type in date or use date picker
What are you authorizing? *

I would like Etheridge Psychology to release my Protected Health Information (PHI) to a person or agency. I would like a person or agency to release my PHI to Etheridge Psychology. I would like Etheridge Psychology and another person/agency to exchange my PHI between them.
Who is the other person or agency you are authorizing? *
Type the name of the person or agency
Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
Address if known

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

I understand the following:

The information disclosed may include sensitive information relating to mental health and may contain information regarding sexual abuse/assault, drug/alcohol use, HIV/AIDS and other communicable diseases, and genetic testing that has been disclosed to Etheridge Psychology.

I have the right to inspect or copy the PHI that is used or disclosed and that I must make a request to inspect or copy the information from the provider who is disclosing the information, not the provider receiving the information.

I may cancel this authorization at any time in writing to Etheridge Psychology. Revocation of this authorization will not affect any disclosures of PHI made prior to revocation of this authorization.

Once my PHI is disclosed, it may be re-disclosed by the recipient of the information who may not be bound by the same privacy laws governing the practice of psychology.

I understand I am not required to sign this authorization, my treatment is not conditioned upon the signing of this document, and I may have any questions regarding this document answered prior to my signature or refusal.

This authorization will be in effect and valid for one year from the date of signature unless revoked in writing.
Is this patient a minor (under age 18) or a legally dependent adult? *

Yes No
Minor children: A parent or legally appointed guardian of a minor child must sign this form. A step parent is not a legally appointed guardian unless a court has appointed them as a legal guardian with authority to consent to health care services for the minor patient.

Dependent adults: A legally appointed guardian with authority to consent to health care services for the patient must sign for the patient.
Name of parent or legally appointed guardian *

First Name Last Name
Relationship to patient *
Electronic Signature

By completing the following fields, you affirm that you have read this document, that you agree to the terms and conditions, and that you consent to sign this document electronically. You are not required to sign electronically and may request this document in non-electronic form. You have the right to withdraw your consent to further electronic disclosures, in writing, at any time. You have the right to receive a copy of your completed form. You may reach us by phone at (919) 600-4906, and our address is 115 Kildaire Park Dr Ste 313, Cary, NC 27518. If you are signing this document on behalf of a legal dependent (such as a minor child), you attest that you have the legal authority to sign on behalf of this patient without the approval of another person (such as a minor's other parent).
Name of person signing this form electronically

First Name Last Name
Signature of patient or legally appointed guardian or representative *

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