• Limited Patient Authorization for Disclosure of Protected Health Information (PHI)

    Form must be signed and dated each year.

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  • Purpose of request (who will be authorized to receive information) - I authorize the entity identified above to disclose or provide protected health information, about me to the individual(s) listed below.

     

  • Description of information to be disclosed - I authorize the practice to disclose the following protected health information about me to the entity, person, or persons identified above:

    • You have the right to terminate this authorization at any time by submitting a written request to our Privacy Manager.  Termination of this authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization.
    • The practice places no condition to sign this authorization on the delivery of healthcare or treatment.
    • We have no control over the person(s) you have listed to receive your protected health information.  Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule, and will no longer be the responsibility of the practice.
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  • You have the right to receive a copy of signed authorizations upon request.

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