• AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION

    AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION

  • Patient Information:

  •  - -
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  • Requesting records from:

  • I understand that the health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards and my health information might be re-disclosed without obtaining my authorization.

    I understand I have the right to:

    • Receive a copy of this authorization
    • Refuse to sign this authorization and that treatment, payment, enrollment in a health plan or eligibility for health care benefits may not be contingent on my signing this authorization
    • Revoke this authorization, except to the extent that the person(s) and/or organization(s) listed above have already made in reference to this authorization

    This authorization will remain in effect for 12 months from the date signed below.

  • Clear
  • If signed by a Legal Representative (authority to act on patient's behalf): Relationship to Patient:      

  • Should be Empty: