Record Request

East Bay Psychopharmacology Group

3860 Blackhawk Road, Suite 120, Danville CA 94560

P: (925)264-4069 F:(925) 577-7608 E: ebpgoffice@comcast.net

Said A. Ibrahimi, MD J. Kirk Hartman, MD Ameek Mundi, DO

Authorization for Use and/or Disclosure of Patient Health Information

Completion of the document authorizes the use and/or disclosure of your health information. Please read the entire document before signing.

Patient Name *

First Name Last Name

Patient Date of Birth *

Date

Person completing form (must be parent/guardian): *

First Name Last Name

Relation to Patient *

I hereby authorize East Bay Psychopharmacology Group (EBPG) to release my health information to:

Healthcare Provider to Release Information to (please provide professional's name and/or company) *

Professional/Company Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

Fax Number *

Area Code Phone Number

I authorize the release of the following health information to the above professional/company: *

All health information about my medical history, mental health history, and treatment received Only the following type of health information (please use text box below):

Expiration - This authorization expires one year from the date of my signature unless a different date is specified here:

Revocation: I understand that I may cancel this authorization at any time, but I must do so by submitting my request for revocation to the EBPG authorized to release the information. My revocation will take effect upon receipt, except to the extent that others have acted in accordance with this agreement.

Notice of rights: I understand that I do not have to sign this authorization. By refusal will not affect my ability to obtain treatment, payment, or eligibility of benefits.

I understand that I have a right to receive a copy of this authorization.

I further understand that information disclosed by this authorization, may be re-disclosed (given to) another person or agency and may no longer be protected by federal confidentiality law (HIPAA). However, California law does not allow the person receiving my health information by this authorization to disclose it unless a new authorization for such a disclosure is obtained from me or unless such disclosure is specifically required or permitted by law.

*

I have read the above information on this authorization and agree to the use and disclosure of health information specified above.

Parent/Guardian Signature for Record Release: *

Clear

Date of Signature: *

Date