Patient Authorization to Disclose PHI

PATIENT AUTHORIZATION TO DISCLOSE MEDICAL EXPENSE REPORT
Name
Address
City, State, Zip
Date of Birth

MonthDayYear
Date
1. I hereby authorize Bayshore Pharmacy to disclose my Patient Prescription Record (PPR), reflecting information regarding my pharmacy services as set forth below: 1. My Patient Prescription Record (PPR), may be disclosed to the following person(s):
Name
Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
2. I understand that I may revoke this authorization at any time by writing to Bayshore Pharmacy, 2 Bayshore Plz, Atlantic Highlands NJ 07716, except to the extent that Bayshore Pharmacy has taken action in reliance on this

3. I understand that I am signing this Authorization of my own free will and that this authorization will not affect my ability to obtain treatment from the Pharmacy. I hereby state that this disclosure is at my request. A photocopy or facsimile of this signed authorization is as valid as the original and will be accepted. 4. I understand that if the person or entity that receives my PPR is not required to comply with the federal privacy regulations, the information described above may be redisclosed and would no longer be protected by those regulations. 5. This Authorization will expire 6 months from the dated signature on this authorization.
Signature of Patient

Clear
*To the patient's personal representative, explain your authority to act on behalf of the patient to receive medical

E-Mail: Manager.BayshorePharmacy@comcast.net
Should be Empty:

PATIENT AUTHORIZATION TO DISCLOSE MEDICAL EXPENSE REPORT