Authorization for Release of Information

Authorization for Release of Information
Patient Name:

First Name Last Name
Date of Birth

Month Day Year
Date
Social Security Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.

Authorize PSIMED INC. to Release Information To:

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Authorize PSIMED INC. to Obtain Information From:

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
I specifically authorize the release of this information:
Signature of patient/legal guardian/authorized person

Clear
Information is being released for the following purpose (s)
Please specify other here:
Date From:

Month Day Year
Date
Date To:

Month Day Year
Date
Signature of Patient/legal guardian/authorized person

Clear
I understand the following:

*This authorization will expire 1 YEAR from the date this form is signed.

*I may revoke this authorization at any time by notifying the providing organization in writing.

*My notification will be effect on the day it is received, unless action has already been taken on the original request.

*The information used before this authorization may subject to redisclosure by the recipient and no longer protected by federal privacy regulations.

ACKNOWLEDGEMENT: I have had the opportunity to review the contents of this authorization. By signing below, I am certifying my agreement with the statements made in this form and agreeing to the release of my protected health information as indicated on this form.
Patient Name:

First Name Last Name
Signature of patient/legal guardian/authorized person

Clear
Date

Month Day Year
Date
Should be Empty: