• Authorization of use and Disclosure of PHI

  • Expiration Date of Authorization

  •  - -Pick a Date
  • Right to Terminate or Revoke Authorization

    You may revoke or terminate this authorization by submitting a written revocation to our office. You should contact the HIPAA Compliance Officer to terminate this authorization.
  • Potential for Re-disclosure

    Information that is disclosed under this authorization may be re-disclosed by the person or organization to which it is sent. The privacy of this information may not be protected under the Federal Privacy Rule depending on whom the information is disclosed to. Our practice will not condition treatment, payment, enrollment or eligibility for benefits on whether the individual signs this authorization.
  • _______________________________________________________________________
    Signature of Patient                                                                                     Date

  • _______________________________________________________________________
    Patient Representative and Relationship (if applicable)                                    Date

  • _______________________________________________________________________
    Physician Signature                                                                                      Date

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  • Should be Empty: