Authorization to use and disclose PHI CD

I hereby authorize use and/or disclosure of the named individual's health information as described below:
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Guarantor name if patient is under 18

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
The following individual or organization is authorized to make this disclosure;*

ClearviewDermatology,LLC (aka Leominster Dermatology LLP) may disclose protected healthinformation (PHI) of the above named patient to the individual and/ororganization listed below;The individual and/or organization listed below may disclose protected health information (PHI) to Clearview Dermatology, LLC on behalf of the above named patient.
Name of Individual or Organization to Release Records To;*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Records May Be;*

Mailed to aboveFaxed to aboveElectronic Copy
Purpose of release of PHI*

Patient AccessTransfer out of practiceTo health or other insurance (such as life or disability)AttorneyOther
Initial below if you DO NOT want the following items, which may appear in your records, be authorized for use and/or disclosure.*

HIV/AIDS related information or recordsPsychotherapy notesOther mental health information, communication and/or recordsInformation acquired by any social worker consulting me in their professional capacityContain communications between myself and any psychotherapist,psychologist, or allied mental health professionalGenetic testing information and/or recordsContain any blood alcohol test resultsRelated to venereal diseaseRegard a child born out of wedlockALL of the above are Ok to release
I understand as the patient or person authorized to act on the patient’s behalf the following applies;

·         I am entitled to receive a copy of this authorization, and the requester may be provided a copy of this authorization.

·         I am entitled to inspect my records and that a reasonable fee may be charged for the records.

·         I may revoke this authorization in writing at any time, except to the extent that release has been made prior to my revocation in reliance on this authorization and that such release shall not constitute a breach of my right to confidentiality.

·         I understand that Clearview Dermatology, LLC does not, and cannot control how a recipient uses or shares any information provided to the recipient in accordance with the authorization and that the recipient may not be bound by the same obligations as Clearview Dermatology, LLC

·         I understand that my treatment, and receipt of services at Clearview Dermatology, LLC will not be affected by signing this form, or refusal to sign this form.

I hereby release Clearview Dermatology, LLC (and subsidiaries), its professionals, employees and agents from all liability arising from this authorized disclosure of my health information. Unless otherwise revoked, this authorization will remain in effect from the of this Authorization for one year, unless otherwise indicated. I understand there may be a fee involved for the reproduction of the requested health information. The fee charged, as allowed by applicable Massachusetts law, may vary depending on the number of pages being copied.
Signature of Patient or Representative **Patient must be over 18 to sign on his/her own behalf*

Clear
Name*

First NameLast Name
Date

MonthDayYear
Date
Should be Empty: