• MEDICAL WELLNESS CENTER OF GEORGIA, LLC

  • AUTHORIZATION FOR RELEASE/DISCLOSURE OF HEALTH CARE INFORMATION

  •  / /
    Pick a Date
  • I authorize the release and disclosure of my health information as described below:

    Records relating to treatment dates

  •  - -
    Pick a Date
  •  - -
    Pick a Date
  •  

    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)

     

  • 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.

  • Clear
  •  / /
    Pick a Date
  • Clear
  •  / /
    Pick a 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: