Authorization to Use or Disclose of Protected Health Information

A Valid authorization must be obtained prior to use or disclosure of protected health information , except for treatment, payment or health care operations as noted in the Privacy Notice.

 

Instructions:

Complete the questions below print sign the upload the document using the links

 
 

I authorize the facility identified above to use and disclose the health information pertaining to the patient identified as described below:

 

Name

 
Phone
 
 
 
 
 

This authorization may be revoked in writing at any time with the following exceptions:

  1. The facility has already taken action in reliance thereon; or
  2. If the authorization was obtained as as condition of obtaining insurance coverage, it will not apply to my insurance company if the law provides my insurer with the right to contest a claim under my policy.


 

The information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by the Privacy Rule.


This auhorization is signed voluntarily. I understand that i can refulse to sign this authorization and that i need not sign this form in order to receive treatment.

 
 

Upload documents using the link(s) below:

Drivers license or picture ID of requestor:

 
 

Use this link to upload your documents to support request. See list below:

Drop your files here