• Authorization To View/Disclose/Copy PHI

    Authorization To View/Disclose/Copy PHI

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

    FROM: Relief Allergy & Sinus Institute

  • NOTE: If you are requesting records due to a move or relocation, please fill out the forwarding address and phone information below:

  •  / /
    Pick a Date
  •  / /
    Pick a Date
  •  / /
    Pick a Date
  •  / /
    Pick a Date
  • 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.

  • Clear
  •  / /
    Pick a Date
  •  / /
    Pick a Date
  • Clear
  •  / /
    Pick a Date
  • 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: