PHI Disclosure Form

Authorization To View/Disclose/Copy PHI
Patient Name
Phone
Address

Street Address

Street Address Line 2

CityState

Zip Code
Social Security #
Date of Birth

MonthDayYear
I authorize the use, copying and/or disclosure of the above-named patient’s health information as described below:

FROM: Relief Allergy & Sinus Institute
TO:

Parent(s) or guardianRelative or other family memberOther
Parent(s) or guardian (Name)
Relative or other family member (please specify by name and relationship to patient)
Other (Name)
Other (Address)

Street Address

Street Address Line 2

CityState

Zip Code
FOR THE PURPOSE OF: (Check all that apply.)

Viewing Health Information Only (Inspect)Continued Care (Patient Moving or Relocating – Provide new information below)Continued Care (Referral/Consult/Communication)LegalInsuranceCopying at Request of PatientOther (please explain)
NOTE: If you are requesting records due to a move or relocation, please fill out the forwarding address and phone information below:
New Address

Street Address

Street Address Line 2

CityState

Zip Code
Contact Phone Number
INFORMATION TO BE VIEWED, DISCLOSED AND/OR COPIED: The type and amount of information to be used, disclosed, or copied is as follows:

Record AbstractHistory & PhysicalEntire RecordList of AllergiesSkin Test ResultsLaboratory Results (specify dates below)X-ray and Imaging Reports (specify dates below)Consultation Reports (specify doctors’ names below)Other
Laboratory Results from (date)

MonthDayYear
to (date)

MonthDayYear
X-ray and Imaging Reports from (date)

MonthDayYear
to (date)

MonthDayYear
Consultation Reports from (doctors’ names)
This authorization automatically expires 365 days from the date this authorization is signed by the patient below unless otherwise noted.

This authorization provides that:
- I may revoke this authorization at any time, provided the revocation is in writing to the Privacy Official at this practice, except if this practice has taken action relying on this consent or if the authorization was obtained as a condition of obtaining insurance.
- I understand that if the person(s) or entity receiving this authorized PHI is not a health plan or health care provider covered by federal privacy regulations, the authorized information may be re-disclosed by the recipient and may no longer by protected by federal or state law.
- This practice will not withhold treatment for my condition, on my providing authorization for the requested use of disclosure.
Signature of Patient or Authorized Representative

Clear
Date

MonthDayYear
If Signed by Authorized Representative, Relationship to Patient
Date

MonthDayYear
Signature of Witness

Clear
Date

MonthDayYear
If unable to sign document, give reason
Identification verified
Initials
NOTE: Re-disclosure of this information may be permitted.

Our practice charges a nominal fee for the copying of PHI records. If you ask us to mail your requested records, a fee to cover postage will be added to the copying fee. Please contact our Privacy Official if you have any questions relating to your request to copy records.

You have a right to a copy of this form after you sign it.
Should be Empty:

Authorization To View/Disclose/Copy PHI