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  • 8383 Millicent Way (318) 797-6661

    Shreveport, LA 71115 Fax (318)795-8512

    AUTHORIZATION TO DISCLOSE PERSONAL HEALTH INFORMATION

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  • SEND INFORMATION TO: (please be specific)

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  • INFORMATION TO BE RELEASED FROM: (please be specific)

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  • PURPOSE OF DISCLOSRE: Transfer of care

  • If the patient is unable to sign, please indicate such and the authority to act of the person whoissigningfor the patient.This formmust be dated within 90 days of receipt, and may be revoked at any time, providing the information has not already been disclosed. Please see our Notice of Privacy Practices for instructions as how to revoke authorization. We will not condition treatment on the completion of the authorization. Also, please be aware that once we disclose this information per your instructions the information is subject to re-disclosure and may no longer be protected by the HIPAA of 1996.

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  • DISCLOSURES REQUIRING SPECIAL CONSENT:

    My signature below specifically authorizes the release of healthcare information relating to the testing, diagnosis, or treatment for: 

  • My signature below specifically authorizes the release of healthcare information relating to the testing, diagnosis or treatment for: Sexually Transmitted Diseases HIV/Aids Virus Drug/Alcohol Abuse Treatment Mental Health/Psychiatric Disorders

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