New Patient Questionnaire

INTEGRAL HEALTH ASSOCIATES
Authorization for Release of Confidential Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I authorize Integral Health Associates to release and obtain protected information regarding the above named person as indicated below to and from:
Name of person or organization*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Fax

Area CodePhone Number
This authorization applies only to the following protected health care information:*

All pertinent health care informationSummary of treatment, including diagnosisDiagnoses, dates of service, and proceduresHIV related informationLabworkAlcohol and/or drug treatment recordsOther
During the time period or date(s):*

AllOther
For the following purpose(s):*

Continuing Care/Treatment PlanningMedical Leave/AccommodationInsuranceLegalOther
I understand that the information released may contain health care information relating to testing, diagnosis and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health or drug/alcohol treatment.

I understand that signing this authorization is voluntary.

I understand that information disclosed based on this authorization may be subject to redisclosure by the recipient, and no longer protected by federal privacy regulations.

I understand that I may revoke this authorization at any time by making a written instruction to Integral Health Associates.

A photocopy or facsmile of this form will be considered as valid as the original.
This authorization will*

remain in effect as long as I am a patient in the care of Integral Health Associates.expire one year from the date signed.expire on the date entered below:
Expiration date

MonthDayYear
Date
Signature of Patient/Authorized Guardian (Click on signature line):
Signature*
Date

MonthDayYear
Date
Please verify that you are human*
When you are finished completing the form, please click the submit button below.
Should be Empty:

Authorization for Release of Confidential Information