Primary Care Release

Name

First NameLast Name

Date of Birth

DD/MM/YEAR

Authorize to:

Release To:Obtain From:

Person:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Fax Number

Area CodePhone Number

Specific Items ex. Labs, Progress Notes, Medical History

I understand that I may cancel this authorization at any time by signing a separate revocation form. The revocation will not apply to information that has already been released in response to this authorization. I also understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. This authorization will expire in one year from the date of the signature below and may be used until such time for either a one time release or periodic release of information. We will not receive payment or other remuneration from a third party in exchange for using or disclosing your PHI.If the disclosure is for educational purposes, I understand that the recipient may be my child’s home school district and any school within the home district. Disclosure to any other school or educational entity requires a separate authorization. I understand that authorizing the disclosure of this information is voluntary. I understand that I can refuse to sign this authorization but that doing so will affect my provider’s ability to render appropriate care and treatment. I understand that I have a right to receive a copy of this authorization. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure by the recipient, and the information may not be protected by the Federal privacy rules or by New York State law. I further understand that my records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and New York State Mental Hygiene Law section 33.13 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that this authorization may include disclosure of information relating to MENTAL HEALTH TREATMENT, except psychotherapy notes. In the event my health information includes this type of information, I specifically authorize release of such information to the person(s) indicated above. SIGNATURE (UNDER 18 GUARDIAN SIGNATURE): *

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Date

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Signature

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Date

MonthDayYear

2023 General Release