Name of practice:
*
Patient Name:
D.O.B.
I. My Authorization
You may use or disclose the following health-care information (Check- all that apply): All my health information maintained by the above named practice (select include or exclude for each of the following)
My health information related to drug use
Include
Exclude
My Health Information related to alchol abuse
Include
Exclude
My Health Information related to HIV/AIDS
Include
Exclude
My health information related to psychological or psychiatric conditions, including,
Include
Exclude
Psychotherapy Notes
My health information relating to the following treatment or condition:
My health information for the date(s)
Other:
You may disclose this health information to:
Neubauer Hyperbaric Neurologic Center Dr. Richard Neubauer/Dr. George F. Daviglus 4001 Ocean Drive Suite 105 Lauderdale by the Sea, FL 33308 Phone: (954)771-4000 Fax: (954)776-0670
Reasons for Authorization:
This Authorization expires on (date)
or when the following event occurs
II. My Rights
I understand I do not have to sign this authorization in order to get health-care benefits (treatment, payment, enrollment). However I do have to sign an authorization form to: take part in a research study or to receive health-care when the purpose is to create health information for a third party.
I may revoke this authorization in writing. If I do, it will not affect any action already taken by the above named practice based upon authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. Two ways to revoke this authorization are: Fill out a revocation form. The form is available from the office or write a letter to the office.
Once the office discloses health information, the person or organization that receives it may redisclose it. Privacy laws may no longer protect it.
Patient or legally authorized individual signature
*
Date:
*
Time:
*
Submit
Should be Empty: