Authorization to Disclose Health Information

Patient Legal Name*

First NameLast Name
Patient's DOB*

MonthDayYear
Date
AUTHORIZATION:
I hereby authorize Vitalitas Denver, PC to disclose the following information from my medical record:*

Entire recordAssessmentTreatment InformationPsychotherapy NotesOther
If you selected "other" please explain here:
I hereby grant authorization to:
Name:
Address: *
Telephone number:

Name:
Address:
Telephone number:

Name:
Address:
Telephone number:

The purpose of this requested use or disclosure is:
This Authorization shall expire upon:*

Fulfillment of this requestOne year from the date of this authorization, unless revoked sooner by me
Please Confirm*

I acknowledge that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results or AIDS information, and hereby consent to the release of such information.
Please Confirm*

I understand that this authorization may be revoked by me in writing at any time except to the extent that action has been taken in reliance upon it.
Please Confirm*

I understand the information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer protected.
Please Confirm*

I understand that the health care provider identified above may not condition treatment, payment, enrollment in a health plan, or eligibility for benefits on my providing this authorization.
Please Confirm*

I understand that the requestor may copy the information to be used or disclosed.
Please Confirm*

I have read the above and authorize the disclosure of the protected health information as stated.
Please Confirm*

A photocopy or facsimile of this authorization shall be as effective as the original.
Today's Date*

MonthDayYear
Date
Client / Guardian’s Name*

First NameLast Name
Client / Guardian’s Signature

Clear
Please verify that you are human*
Should be Empty:

AUTHORIZATION: