Authorization for Use or Disclosure of Protected Health Info

Advanced Specialty Care, P.C.

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
Medical Records Fax: 888-239-5013

107 Newtown Rd, Danbury, CT 06810
Privacy Officer: Jennifer Retter

As required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Connecticut law, this practice may not use or disclose your individually identifiable health information without your authorization except as provided in our Notice of Privacy Practices. Your completion of this form means that you are giving permission for the uses and disclosure described below. It may be invalid if not fully completed.
Name of Patient whose records are being requested:*

First NameLast Name
Patient's date of birth:*

MonthDayYear
Date
Please check Specialty of records needed:*

Ear, Nose & ThroatDermatologyPlastic SurgeryAllergy & AsthmaAudiologyTest results only
Please enter Provider's name:*
Please list specific types of health information to be disclosed:*
I understand that this health information may include HIV-related information and/or information relating to diagnosis or treatment of psychiatric disabilities and/or substance abuse and that by signging this form, I am authorizing such information to be disclosed.
I authorize Advanced Specialty Care to obtain my medical records FROM:
Name
Address
Fax Number
I authorize Advanced Specialty Care to send my medical records TO (for a fee of 65 cents per page, we will inform you of total fee due prior to records being sent):
Name
Address
Fax Number
Reason for request:*
Effect of Refusal to Sign Authorization

I understand that my refusal to sign this Authorization will not jeopardize my right to obtain present or future treatment for psychiatric disabilities except where disclosure of the information is necessary for the treatment.

I understand that I may revoke this authorization at any time by notifying this medical practice in writing. My revocation will not affect actions taken by this medical practice prior to its receipt.

I understand that, if the recipient of the information is not a health care provider or health plan covered by the federal Privacy Rule, the information used or disclosed as described above may be re-disclosed by the recipient and no longer protected by the Privacy Rule. However, other state or federal law may prohibit the recipient from disclosing specially protected information, such as substance abuse treatment information, HIV/AIDS-related information, and psychiatric/mental health information.

This authorization is effective indefinitely unless revoked in writing.

I understand that I have the right to receive a copy of this authorization.
Sign your name:*

Clear
Type your name:*

First NameLast Name
Today's date:*

MonthDayYear
Date
Should be Empty:

Advanced Specialty Care, P.C.