Release of Records - TO Specialty Natural Medicine FROM Outside Clinic or Individual

Patient Name – Last, First, Middle*

Patient Date of Birth*

Date

Patient Phone Number*

2.Purpose or need for disclosure – may be released electronically (CHOOSE

ONE:*

My health information is being disclosed at my request;My health information is being disclosed for the following purpose:

Reason for request (if "My health information is being disclosed for the following purpose" was selected above

Record are being released TO Specialty Natural Medicine, Inc from an outside Clinic or Provider:

Releasing Clinic, Provider Name or Individual*

Releasing Clinic/Physician Address (City, State)*

Releasing Clinic/Physician Phone Number

Releasing Clinic Fax Number

5.Records to be Disclosed (Check One):

Comprehensive overview of chart contains all discharge summaries, all clinical notes, all pathology reports, and all clinical summaries, x-ray reports, EKG and lab reports):Records Pertaining to:

Records Pertaining to:

If applicable. Leave blank if you would like all records from date range below.

From Date:*

Date

To Date:*

Date

Unless otherwise indicated, I authorize sensitive information about my conditions which may include sexually transmitted disease, acquired immunodeficiency syndrome AIDS, or human immunodeficiency virus HIV My health record may also include sensitive information about behavioral or mental health services and treatment for alcohol or drug abuse or results from genetic testing.

Do not include this sensitive information.

I understand and agree that:

This authorization is voluntary;
My health information may contain information created by other persons or entities including health care providers and may contain medical, pharmacy, dental, vision, mental health, substance abuse, HIV/AIDS, psychotherapy, reproductive, communicable disease and health care program information;
I may not be denied treatment, payment for health care services, or enrollment or eligibility for health care benefits if I do not sign this form except (1) if my treatment is related to research, or (2) health care services are provided to me solely for the purpose of creating protected health information for disclosure to a third party ;
My health information may be subject to re-disclosure by the recipient, and if the recipient is not a health plan or health care provider, the information may no longer be protected by the federal privacy regulations;
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Specialty Natural Medicine. I understand that the revocation will not apply to information that has already been released in response to this authorization. I 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.
I agree that my signature on this document (hereafter referred to as my "E- Signature") is as valid as if I signed the document in writing. I also agree that no certification authority or other third party verification is necessary to validate my E- Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of my E-Signature or any resulting agreement between Specialty Natural Medicine, Inc PC. and me.

This authorization is voluntary;

By electronically signing this form, I acknowledge that I have read and agree to all terms of this form.

Signature of Patient or Authorized Guardian*

Date*

Date

If signed by person other than Patient, Provide Name, Relationship and Description of Authority