FIrst Name *
FIrst Name
Middle Name
Middle Name
Last Name *
Last Name
Former Name
Former Name
Patient Address *
Patient Address
Date of Birth *
Date of Birth
Preferred method of communication *
Patient Phone Number
Patient Phone Number
I authorize the disclosure of protected health information about me *
Individual/Entity Name *
Individual/Entity Name
Individual/Entity Name* *
Individual/Entity Name*
Individual/Entity Phone Number *
Individual/Entity Phone Number
Individual/Entity Fax Number *
Individual/Entity Fax Number
Delivery Method *
Purpose of disclosure *
When this authorization expires* *
Signed by *
- This authorization will expire at the end of the calendar year of your last signature below, unless you specify an earlier termination. You must renew or submit a new authorization after the expiration date to continue the authorization. - You have the right to terminate this authorization at any time by submitting a written request to our Privacy Manager. Termination of this authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization. - The practice places no condition to sign this authorization on the delivery of healthcare or treatment. - We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule, and will no longer be the responsibility of the practice.