Intrepid - AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
I...*

First NameLast Name
DOB

MonthDayYear
Date
...hereby authorize disclosure and release of my Protected Health Information in specifications listed below.
Authorization Given To:
Name of Physician or Facility*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax number*
Please enter a valid phone number.
Release Records To:

Intrepid Research, LLC
4421 Eastgate Blvd. Suite 200
Cincinnati, OH 45245
Fax:513-943-8150
PHI/information to be disclosed/released:*

All medical recordsHospital medical recordsPhysician office notesLaboratory/pathology recordsX-ray/radiology records, images (CD)Last History & physicalMedication ListBilling recordsOther
Describe Specifically*
This protected health information is being released for the following purposes: *
(List specific purposes above.)
This authorization shall be in force and effect until one year after this request has been signed.

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to Sleep Management Institute/Intrepid Research, LLC .

I understand that information released pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.

Intrepid Research, LLC will not condition my treatment, payment, enrollment in a health plan or eligibility for benefits (if applicable) on whether I provide authorization for the requested disclosure.

I understand that I have the right to: Inspect or copy the protected health information to be disclosed as permitted under federal law.

I understand that this Authorization allows the Health Care Provider (and its team members) to discuss my individually identifiable health information described herein with the recipient of the information.

For more please see our T erms of Use and HIPAA Policy.
Refuse to sign this authorization.Consent and reviewed the Terms of Use and HIPAA Policy.
Signature of Patient or Patient Representative*

Clear
Signature of Patient or Patient Representative (written)*
DateTime*
Name of Patient or Patient Representative*

First NameLast Name
Description of Patient Representative’s Authority*
Should be Empty: