Authorization for Release of Protected Health Information

Authorization For Release Of Protected Health Information

First Name(Required)

Last Name(Required)

DOB

Email

Authorization For:

To disclose my healthcare information.

Healthcare Information

You may disclose the following healthcare information:

You may disclose this health information to:

Name/Organization

Address

Fax Number

Phone Number

Purpose of this authorization: continuity of care.

My Rights:

I understand that I may revoke this authorization in writing by sending a letter to the healthcare provider to whom the authorization is directed. If I did, it would not affect any actions already taken by the healthcare provider based upon this authorization.
I understand that once the healthcare provider discloses my health information, the person or entity that receives it, may re-disclose it. The HIPAA Privacy laws may no longer protect my health information.