AUTHORIZATION FOR RELEASE/DISCLOSURE OF HEALTH CARE INFORMATION

MEDICAL WELLNESS CENTER OF GEORGIA, LLC
AUTHORIZATION FOR RELEASE/DISCLOSURE OF HEALTH CARE INFORMATION
Patient Name*
DOB*
Today's Date*

MonthDayYear
Date
Address*
Guardian or Authorized Party (if applicable)
DOB
I authorize the release and disclosure of my health information as described below:

Records relating to treatment dates
From

MonthDayYear
Date
To

MonthDayYear
Date
All Records at the facility or by this provider listed below:

YesNo
Other (Please Specify)
Name of Facility or provider releasing records
I understand that I have the right to revoke this authorization in writing at any time, except (1) where uses or disclosures have already been made based upon my original permission or (2) the authorization was obtained as a condition of securing insurance coverage and the insurer by law has therightcontest a claim or the insurance policy. I understand that uses and disclosures already made based upon my original permission cannot to be taken back. To revoke this authorization, I must do so in writing and without my express revocation, this consent will automatically expire days from today's date. I understand that it is possible that information used or disclosed with my permission may be re-disclosed bytherecipient and no longer protected by the Federal Privacy Standards.(Initials of patient or guardian)
Information to be Released From:*
Ph*
Choose Clinic Location*

MEDICAL WELLNESS CENTER OF GEORGIA,LLCOther
FAX NUMBER
Email
example@example.com
OR MAILING ADDRESS
I understand that the provider above may not condition treatment on my signing this authorization and that I have a right to refuse to sign.
Signature of Patient or Guardian

Clear
Date*

MonthDayYear
Date
Signature of Witness

Clear
Date

MonthDayYear
Date
** If authorization is signed by a personal representative, the representative's authority is based on

(e.g., state law, court order, POA, etc

FEE SCHEDULE: State and Federal laws specify a reasonable fee may be charged to offset the cost associated with the reproduction of records. No fee shall be charged for reproducing and forwarding records directly to other physicians.

Notice to Patients: By choosing to utilize Email communication, you are acknowledging that email may not be completely secure. Selection of Email option and signature are documentation of patient and/or guardian acknowledgment of these risk and hereby grant permission to utilize email.

A fax copy, or photocopy of this consent shall be as valid as the original.
Should be Empty:

MEDICAL WELLNESS CENTER OF GEORGIA, LLC

AUTHORIZATION FOR RELEASE/DISCLOSURE OF HEALTH CARE INFORMATION