• East Bay Psychopharmacology Group

    3860 Blackhawk Road, Suite 120, Danville CA 94560

    P: (925)264-4069 F:(925) 277-1116 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. 

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

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  • 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.

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